
Book '38 



COPYRIGHT DEPOSHi 



PERIODONTAL DISEASE 



TREATMENT BY IONIC MEDICATION 



BY 
ERNEST STURRIDGE, L.D.S. (Eng.), D.D.S. 

iUTHOR OF "DENTAL ELECTRO-THERAPEUTICS," CONTRIBUTOR ON DENTAL 

ELECTRO-THERAPEUTICS IN " THE SCIENCE AND PRACTICE OF DENTAL 

SURGERY," ON IONIC MEDICATION IN PRINz'S " DENTAL MATERIA 

MEDICA AND THERAPEUTICS," FELLOW OF THE ROYAL 

SOCIETY OF MEDICINE, MEMBER OF THE BRITISH 

DENTAL ASSOCIATION, ETC. 



ILLUSTRATED WITH 66 ENGRAVINGS 




LEA & FEBIGER 

PHILADELPHIA AND NEW YORK 
1919 



^ 



COPYRIGHT 

LEA & FEBIGER 
1919 



NOV II 1919 



A536531 



PEEFACE. 



This book, which is based on conclusions reached after 
over thirty years of experience and study of this most 
difficult problem, is intended to emphasize the local aspect 
of periodontal disease and to demonstrate that much can 
be done in combating the disease by systematizing a definite 
method of treatment to the exclusion of conflicting opinions 
of many writers on vital points of the subject. 

In adopting the view that periodontal disease is purely 
local in origin, the writer has gone to much pains to draw 
attention to the incipient stages of the disease and to point 
out that those who ignore or overlook the importance of 
this stage do injustice to their patients. 

Pyorrhoea alveolaris, it has been shown, is but a termi- 
nation of periodontal disease which can be averted by a 
systematized method of dealing with the premonitory symp- 
toms, but these are so often overlooked that the disease is 
now almost universal in the mouths of adult people, even 
in those who frequently consult dentists. 

A strong protest has been entered against reckless whole- 
sale extraction of teeth as the only means of curing the 
disease; many practitioners seem to overlook the symptoms 
of approaching pyorrhoea, or entertain pessimistic views on 
the arrest of the disease by local measures and eventually 
resort to extraction of every tooth in the denture; this is but 



IV PREFACE 

admission of failure to cope with scientific problems which 
it should be our duty to undertake. 

The extraction of certain teeth for the benefit of the patient 
and in the interest of treatment of other teeth is undoubtedly 
often necessary but a high standard should be placed on the 
importance of retaining the organs of mastication and the 
elimination of oral sepsis by available methods. 

Treatment by ionic medication which is advocated, is 
intended to cope with one etiological factor but stress is laid 
on the futility of depending on it alone and the importance 
of dealing with many other factors which are specified. 

It is hoped that some useful hints are given by classifying 
the stages of the disease and giving a definite method of 
treatment for each, also, subdividing the pyorrhoea stage 
with a view of drawing attention to the different phases 
which present knotty problems in the treatment of the dis- 
ease. 

No claim is made that this is the only method of treating 
pyorrhoea alveolaris; on the contrary, the writer is aware that 
many are curing the disease by highly scientific methods 
which, if examined, in every case will be found to consist of 
a definite system followed on lines of strictest attention to 
local etiological factors. 

A short chapter is given on the principle of ionic medica- 
tion, the apparatus and the technic necessary to carry out 
this method of applying drugs; the scope of this work does 
not admit of details on electro-therapeutics or electrophysics 
but it is advisable that a thorough knowledge of these should 
be acquired by those who adopt this treatment, and the 
writer advises them to consult larger works on the subject 
both from a medical and dental standpoint. 

I desire to take this means of expressing my appreciation 



PREFACE v 

of the valuable assistance rendered by friends in the prepara- 
tion of this work, particularly Dr. E. D. Barrows and Dr. 
N. S. Finzi, who kindly provided some of the a>ray illustra- 
tions; to Dr. E. C. Kirk, for advice on the general context, 
and Messrs. Ash & Son and De Tray & Co., for loan of 
blocks. 

E. S. 
London, 1919. 



CONTENTS. 



Introduction 17 

CHAPTER I. 
Etiology of Periodontal Disease 23 

CHAPTER II. 
Bacteria and Mouth Protozoa 31 

CHAPTER III. 
Pathology of Periodontal Disease 37 

CHAPTER IV. 
Toxemic Effects of Periodontal Disease 46 

CHAPTER V. 
Early Diagnosis of Periodontal Diseases 55 

CHAPTER VI. 
Treatment of Periodontal Disease 65 

CHAPTER VII. 

Prognosis of Periodontal Diseases 114 

CHAPTER VIII. 
Notes on Ionic Medication 120 



PERIODONTAL DISEASE, 



INTRODUCTION. 

It would be difficult to name a disease associated 
with more controversial literature than "pyorrhoea alveo- 
laris." Historical evidence places it in the category of one 
of the oldest existing maladies, for anatomical specimens 
in museums which date back to many centuries B.C. reveal 
unmistakable evidence of the disease as known to us today. 
Writers about the middle of the eighteenth century first 
began to describe it, and later on, in the early part of the 
nineteenth century, more frequent reference was made to 
this disorder. About the year 1875 Dr. Riggs first accurately 
described the disease; he regarded it as purely local, and 
treated it from that aspect in a highly satisfactory manner. 
Since then the etiology, pathology and treatment of peri- 
odontal disease has attracted ever-increasing interest and 
been debated on such controversial lines that it has become 
well-nigh impossible to determine, without vast personal 
experience, which are the correct deductions to accept. The 
medical profession has recently discovered the disease, and 
are now imposing their will on the dental profession; some 
are treating it themselves by vaccines, others are condemning 
all teeth affected with the disease to the forceps, while others 
are content with attributing nearly every disease of the 



18 PERIODONTAL DISEASE 

human body to the effects of oral sepsis and saddling the 
dentist with the responsibility of treatment. 

But dentists themselves have not settled on any fixed 
etiology or pathology, and consequently vary in lines of 
treatment to a remarkable degree, and a serious feature of 
consequent inability to cope with the disease is a strong con- 
viction prevalent that under no circumstances is it curable 
when the teeth are retained. There is usually a vague or 
controversial element introduced by even the most recent 
writers on the subject, making it difficult for the most ardent 
student to determine what is meant or which conclusions 
are the correct ones. The disease is usually studied in the 
advanced stages, the preliminary stages being overlooked as 
a gingival affection with no direct bearing. 

Howe 1 in his report on pathology and etiology to the sixth 
International Dental Congress states: "This fully developed 
pathological condition presents three distinct phases. . . . 
I refer to bacterial activity, pathological calcifications, tissue 
degeneration." The last of these is a vague statement over 
which great division of opinion exists and refers to advanced 
stage. 

In a recent and important work — The Science and Practice 
of Dental Surgery, by Norman Bennett, is recorded : " The 
causes of chronic suppurative periodontitis are at present 
very vaguely understood, some writers attribute the disease 
to Constitutional Disorders, while others consider it to be due 
to local irritants. The consensus of opinion seems to favor 
the belief that both play an important part." 

A great deal of stress is laid on the constitutional causes 
by the vast majority of writers, but local causes are always 

1 Sixth Inter. Dent. Congress, p. 115. 



IXTRODUCTIOX 19 

included and so mixed up as to make the student wonder 
which is really the important factor. 

Talbot presented a mass of evidence to demonstrate " that 
the causes of interstitial gingivitis are de visible into predis- 
posing causes (which may be subdivided into local predis- 
posing and constitutional) and exciting causes. The exciting 
causes are either constitutional or local, but as a rule are local 
or have local action." 

For many years the disease was associated with gout, and 
uric acid was made responsible for at least one form of 
pyorrhoea, 1 "in which the local necrosis of the periodontal 
membrane is caused by gouty disease of one of the blood- 
vessels in its substance." 

Xewland Pedley 2 concluded that " 'pyorrhoea alveolaris is 
essentially of constitutional origin," and asserts that "the 
weight of evidence tends to place pyorrhoea alveolaris hi the 
category of bone disease." 

Hopewell-Smith, 3 in his research on Pathohistology of the 
disease, considers that "pyorrhoea alveolaris does not com- 
mence as a gingivitis," but that "it is essentially dependent 
upon an osseous lesion." 

H. P. Pickerill 4 asserts that "The direct cause in all cases 
is infection by pathogenic organisms." 

Miller 5 says : " It is still a matter of debate whether a local 
irritant be at all required to the origination of the disease. 
As regards the participation of bacteria in pyorrhoea alveo- 
laris, our present knowledge of suppurative inflammations 
compels us to consider the former as the cause of the suppura- 

1 Fitzgerald: Pyorrhoea Alveolaris. 2 Dental Record, May, 1887. 

3 Pvorrhoea Alveolaris: Its Pathohistologv. Dental Cosmos, April. 1911, 
p. 397. 

4 Stomatology in General Practice, p. 11. 

3 The Microorganisms of the Human Mouth, p. 332. 



20 PERIODONTAL DISEASE 

tions incident to the disease. Microorganisms which possess 
pyogenic properties, temporarily or permanently, inhabit 
every mouth. If, therefore, the power of resistance of the 
periodontal membrane be impaired by any one of the above- 
mentioned local or constitutional causes in such a manner as 
to furnish a suitable culture medium for the bacteria, they 
will, of course, begin their ravages and the usual symptoms 
will follow." 

G. V. Black was the first to classify the disease from symp- 
toms observed into two classes, both closely allied "gingi- 
vitis" and "phagedenic pericementitis," the former dependent 
on the presence of two forms of calculus and the latter, of a 
more destructive character, he associated with a specific form 
of microorganism, at the time undiscovered, as well as the 
presence of calculus, which causes "an inflammation of a 
peculiar character which results in a destruction of the peri- 
odontal membrane." 1 Black's conception of the disease at 
that time holds good now in many respects. Knowledge has 
been added, but his teachings on the subject laid the founda- 
tion for much of the conservative work now done. 

Recent investigations on the protozoa of the buccal cavity 
by A. Chiavaro, 2 of Rome, and M. T. Barrett, 3 of Philadelphia 
revealed the presence of Entamoeba? buccalis almost con- 
stantly in pyorrhoea pus, and Barrett leans toward the view 
that this protozoa causes the disease, while Chiavaro holds 
the opposite view. 

Colyer, 4 studying the anatomy of chronic general peri- 
odontitis, draws the conclusion " (1) that the bone lesion is 
a progressive rarefying osteitis commencing at the margin 

1 Black, G. V.: Am. System of Dentistry, i, 954. 
- Dental Cosmos, September, 1914, p. 1089. 

3 Ibid., December, 1914, p. 1345. 

4 Chronic General Periodontitis, pp. 30 and 64. 



INTRODUCTION 21 

of the alveolar process, and (2) that the varying density of 
the bone influences the rate of destruction." The cause of 
the disease in man he attributes "to the disease being started 
by injury of the gingival margin from food debris or the local 
action of toxins as seen on the marginal gingivitis of mouth 
breathers." He also points out that ''The prevalence of the 
disease is probably due to the character of the diet of the 
present day." 

Znamensky, 1 studying the disease from the anatomo- 
pathological standpoint, concluded that constitutional dis- 
orders as well as local irritants are responsible for osteo- 
porosis characteristic of the disease. He says: " The different 
diseases which produce an osteoporosis of the bones in the 
whole system, and particularly in the sockets, may be the 
predisposing cause of alveolar pyorrhcea. The diseases of 
general constitutional character which belong to this class 
are osteomalacia, rickets, scrofula, syphilis, acute eruptive 
processes, fevers and typhus. Further, there are also dis- 
eases of the blood, exchange of matter in the system, such 
as anemia, chlorosis, scurvy, leukaemia, hemophilia, diabetes 
mellitus and gout. The causes of atrophy of the tissues are 
scanty nourishment, repeated pregnancy, chronic catarrh 
of the stomach, diseases which exhaust the system, tabes 
dorsalis, tuberculosis and rheumatism." Referring to the 
local causes, on which he lays very little stress, he says: 
"The most frequent of these is an accumulation of tartar 
deposits." He also vaguely refers to local influence of irregu- 
larities of teeth and the use of soft foods. 

These divergent views on etiology and pathology of peri- 
odontal disease here mentioned are but a few selected from 

1 XVIIth International Congress of Medicine, Section XVII, p. 26. 



22 PERIODONTAL DISEASE 

some of the best known recent writers — many more might 
be quoted to emphasize the confusion which exists regarding 
the character of the disease. The great lack of some recog- 
nized system in the treatment of the disease is undoubtedly 
due to these divergencies of opinion as to its cause, for all 
treatment is based on the conception of certain etiology — 
those who believe in constitutional causes, or local causes or 
gouty diathesis, or osseous lesion or pathogenic organisms, 
or protozoa, base their treatment accordingly, and unfortu- 
nately the majority have little real conviction that any form 
of treatment is likelv to succeed. 



CHAPTER I. 
ETIOLOGY OF PERIODONTAL DISEASE. 

No useful etiology of periodontal disease can be based on 
the conception that pus must be visible or present in the diag- 
nosis of the disease. When the recognition of the disease is 
delayed until this stage is reached, the most important stages 
have simply been overlooked until the disease has been in 
existence for a very long time, and it is on this account that 
the very term pyorrhoea, employed to express it, is bad and 
misleading. When pus is exuding or can be expressed from 
the sides of the teeth, the disease has already advanced 
considerably. 

A study of the pathology of the disease should leave no 
doubt in our minds that it is of purely local origin; it only 
needs to be recognized in the incipient stages to impress us 
with the force of this conclusion. The vast majority of cases 
have some local irritant cause or series of local irritant causes 
directly responsible for the starting of that inflammation 
which lends itself to the possibility of septic infection of the 
adjacent tissues. 

The incipient stage of the disease is to be found about the 
gingival margin in what is usually termed gingivitis and not 
generally associated with pyorrhoea. At this stage if the 
gingival trough (Fig. 1) or space be examined, it will be 
found to contain some local irritant in the form of salivary 
calculus or stagnant food or coating of translucent mucous 



24 



ETIOLOGY OF PERIODONTAL DISEASE 



extending from the necks of the teeth into the trough, 
or, in the case of badly kept teeth, quantities of salivary 
calculus on the teeth impinging on the gingival margin. 
This local irritant causes a slight inflammation of the gingival 
margin, which may be general or may be confined to the 
dental papilla?, but wherever there is foreign matter in 
contact with the delicate epithelial lining of that fold of gum 
which constitutes one boundary of the gingival trough, 
inflammation occurs. This inflammation may not be visible 
on the outer surface of the gum (as it often is not in well kept 




Fig. 1. — A, gingival trough; B, alveolus; C, periodontal membrane. 



teeth which are constantly massaged by the brush) but may 
be confined to the gingival trough, extending chiefly in the 
direction of the upper fibers of the periodontal membrane. 
Mouth bacteria are ever present, and when a stagnation 
area is produced it is impossible to designate the precise 
stage at which proliferation of pathogenic bacteria first takes 
place; it is probably at a much earlier stage than usually 
estimated. 

This local inflammation, if left unchecked for any consider- 
able length of time, or if allowed to recur at frequent intervals, 



SUBGINGIVAL CALCULUS 25 

leads to the next stage in the disease, in which the local irri- 
tant is augmented by one of the products of inflammation, 
which is subgingival or serumal calculus. Considerable doubt 
has been expressed by some authors on the existence of this 
form of calculus, and many writers ignore it altogether, but 
there is nothing so certain as the production of this form of 
deposit, when inflammation of the gingival fold occurs. 

Subgingival Calculus. — Subgingival calculus is formed at a 
very early stage in the gingival inflammation, which precedes 
chronic periodontal disease, and is one of the primary causes 
of the severing of the fibers of the periodontal membrane, 
and the rarefying osteitis associated with pyorrhoea alveolaris. 

This form of calculus is derived from "an exudation of 
mucus rich in colloidal material," 1 which exudes from the 
inflamed surface of the gingival fold in direct contact with 
the necks of the teeth; it is a product of the blood, consisting 
of inorganic salts, principally magnesium phosphate, cal- 
cium phosphate and calcium carbonate; the predominating 
salt being dependent upon the amount of surcharge of that 
particular salt present in the blood of the individual. The 
amount of subgingival calculus derived from so small an area 
of inflammation is no doubt exceedingly small at first, and in 
the early stages of its formation on the roots of the teeth only 
amounts to a delicate granular layer, which is difficult to 
detect, but gradually the deposit increases, and itself becomes 
a source of further irritation to the inflamed area immediately 
covering it. It further increases, until it is readily discernible 
in the form of granular nodules or a hard, smooth, brownish 
crust, which adheres firmly to the necks of the teeth. 

Subgingival calculus having once been deposited, inflamma- 

1 Kirk: Operative Dentistry, p. 484. 



26 



ETIOLOGY OF PERIODONTAL DISEASE 



tion seems to take on a more acute form, the gums become 
turgid and heaped up in the interdental spaces (increasing 
the depth of the gingival trough), and become loosened from 
the necks of the teeth, forming a suitable receptacle for 
particles of food. The inflammation extends to the peri- 
odontal membrane and the alveolar bone, the former becomes 
detached and recedes, forming a small pocket, the latter 
is absorbed gradually from its free margin toward the body 
of the bone, and a process of rarefying osteitis starts (Fig. 
2). At this stage bacteria undoubtedly exercise a great 




Fig. 2. — Starting rarefying osteitis. 



influence — hastening the progress of the disease. The con- 
tents of the gingival trough now consist of desquamation 
of the epithelial lining of the gingival trough, dead tissue 
cells, leucocytes and serum exuding from the inflamed 
surface, mixed with mucus and particles of decomposing 
food, altogether providing a most admirable culture medium 
which is kept at the right temperature for the development 
and maintenance of pathogenic organisms. 

Up to this stage no pus is visible and pressure on the gums 
only produces bleeding, but the soft tissues are in a diseased 
state and bacteria contained in the gingival trough find 



SUBGINGIVAL CALCULUS 27 

ready access into the intercellular spaces and capillaries, and 
probably penetrate into the alveolar bone. 

In many well kept mouths some of these symptoms are 
entirely absent — there is no swelling or turgidity of the gums, 
no discomfort, the gingival trough, instead of being widened 
for the reception of foreign matter, appears to be shrinking 
gradually. The gingival margin is thinned and taut about 
the necks of the teeth, the alveolar border has obviously 
absorbed away, and the dental papillae have disappeared 
leaving the necks of the teeth well denned, revealing wide 
interspaces. The teeth may be beautifully kept as far as the 
free margin of the gums, but if the gingival trough be exam- 
ined by passing a delicate probe into it, a finely granular 
layer of subgingival calculus can be detected adhering to the 
necks of the teeth. Sometimes it takes the form of sharp 
nodules. Sometimes this local irritant is readily detected 
in larger quantities on the approximating surfaces of the 
roots of the teeth. Subgingival calculus is the active exciting 
cause of the trouble in these cases, and the process, although 
slower than the acute form already described, is just as sure 
in its destruction of the periodontal membrane and alveolus. 

In these cases there is no loosening of the teeth, and some- 
times the alveolar bone is enlarged over the roots of the teeth 
from the pathological action of a continuous slight inflamma- 
tion. There is also a slight fetor from the region of the molars. 

In the more acute forms, where marked inflammation is 
present, the tissues break down rapidly under the influence 
of bacteria, deep pockets are formed, in which pus collects. 
This may be confined to certain localities, where the inflam- 
mation has existed the longest, or it may be general. As the 
disease advances in severity and the pockets deepen by the 
loss of periodontal membrane and bone, bacteria become 



28 ETIOLOGY OF PERIODONTAL DISEASE 

largely responsible for the maintenance of the inflammatory 
process, which now extends deep into alveolar bone: the 
sockets become enlarged by the absorption of bone salts 
and a rarefying osteitis ensues, affecting the lamella?, lacuna? 
and canaliculi of this transitory bony structure. The teeth 
become loose in their sockets, and every motion of mastication 
tends to increase the process of absorption set up by this new 
irritant which acts as a stimulant to the osteoclasts located in 
the proximity of the alveolar wall surrounding the roots of 
teeth. Pathogenic microorganisms enter the inflamed peri- 
odontal membrane and pass into the alveolar bone, where they 
exercise a deep-seated inflammatory action and are readily 
absorbed in large numbers into the general circulation. The 
system is able to resist this invasion of bacteria only to a cer- 
tain point; beyond this immunity becomes lost and a general 
toxaemia often results. The toxaemic effect of microorganisms 
varies largely with the individual, and those previously or 
at the time affected by constitutional disorders, such as 
gastro-intestinal toxaemia, diabetes, neurasthenia, rheumatism, 
intestinal nephritis, anaemia or any form of toxaemia occurring 
in other parts of the system, would naturally lose immunity 
to the action of bacteria from the pyorrhoea source of infec- 
tion much quicker than those who are otherwise sound. The 
effect of general toxaemia is undoubtedly that it aggravates 
the local affection and makes it more intractable. But 
constitutional disorders cannot be accounted the direct 
cause of the local infection. 

As the disease advances to the last stage, when the teeth 
become so loose that it is a question whether they can be 
retained by any means (Fig. 3), when constant and copious 
discharge of pus indicates the severity of the affection, it will 
often be observed that the roots are smooth and entirely free 



SUBGINGIVAL CALCULUS 



29 



from calculus. This is not due to there never having been 
a deposit previously on them, but to the fact that the exudate 
of the first inflammatory process (from which subgingival 
calculus was first deposited on the upper portion of the roots) 
has been supplemented by infiltration of leucocytes and 
broken-down tissues mixed with microorganisms which con- 
stitute the pus, and this flowing constantly over the surface 
of the root gradually liquefies and dissolves those inorganic 
salts and carries them away, leaving the cementum smooth 
and clean. 




Fig. 3. — Advanced pyorrhoea. 



There are many other local irritant causes, besides those 
so far mentioned, which in some cases are the sole and only 
cause of the starting and maintaining of the disease, together 
with the bacteria, which are always a factor and fulfil the 
final destruction of the tissues concerned. They are often 
of a subtle nature and are readily overlooked in the search 
for the cause of the disease. They sometimes reveal no 
symptoms approaching the common forms of pyorrhoea, and 
their effect is principally on the periodontal membrane and 
the osseous structure of the parts. Prominent among these 
subtle causes is faulty contact points of the cusps of two or 
more teeth; this is brought about by the loss of one or more 



30 ETIOLOGY OF PERIODONTAL DISEASE 

teeth, and among the most obscure of these are cases of 
extractions in early life, which have apparently rectified 
irregularities of the teeth in a simple and sometimes appar- 
ently effective manner. An old practice of extracting the 
four first molars or the second premolars to overcome irregu- 
larities is sometimes responsible for this effect. Sometimes 
the effect can be traced to the loss of a single tooth, usually 
a first molar. This throws undue strain on certain teeth, 
which eventually results in a chronic irritation and inflamma- 
tion of the periodontal membrane, accompanied with bac- 
terial infection and resulting in periodontal disease, starting 
in the teeth affected. 

Adenoids is another obscure cause by which mouth breath- 
ing induces the premonitory symptoms, at a very early 
stage, by impairing circulation in the gingival border. 

Many other local irritant causes are to be found which 
produce more localized effects and provide a starting-point 
at the particular teeth concerned, the other parts of the 
mouth remaining normal. These include ill-fitting crowns 
or bridges, fillings with overhanging cervical margins or 
faulty contact points, abnormal spacing of the teeth, irregu- 
larities of the teeth, ill-fitting dentures, insufficient use of 
the teeth and the use of soft, pappy foods, these last two 
having a general influence on the whole denture. With all 
these local causes microorganisms are intimately concerned, 
and after a certain stage of advancement of the disease they 
may continue to maintain the progress of the disease even 
after the local irritant cause has been removed, giving the 
impression that pathogenic organisms are a direct cause of 
the disease. 



CHAPTER II. 
BACTERIA AND MOUTH PROTOZOA. 

BACTERIA. 

One of the most important factors which has to be taken 
into consideration in every case of periodontal disease is the 
bacteria which are associated with the suppurative inflamma- 
tion characteristic of the disease. Microorganisms, which 
possess pathogenic properties, are always present in the oral 
cavity of healthy as well as impaired subjects. Whether 
pathogenic bacteria are capable of starting the irritation, 
which would lead to the establishing of the disease without 
the cooperation of any mechanical local irritant, is a question 
which does not seem to have been decided by authorities on 
the subject. Miller, 1 referring to this, says: "I am not able 
to form any decision regarding this matter, but so much is 
unquestionably certain, that the symptoms are greatly aggra- 
vated by local irritants, and that a removal of all irritations 
and extreme cleanliness are imperatively necessary in contend- 
ing against this disease." It may be taken as an established 
fact, however, that whenever a slight irritant exists and has 
caused the appearance of the disease in a localized area of 
the mouth the pathogenic bacteria are capable of spreading 
the inflammation to adjacent parts and establishing the 
disease practically all over the mouth. 

This fact is of great significance, because it points to the 

1 Microorganisms of the Human Mouth, p. 332. 



32 BACTERIA AND MOUTH PROTOZOA 

important change which takes place in these microorganisms, 
which in healthy mouths are perfectly harmless, but in the 
changed environment resulting from existing disease are 
capable of becoming pathogenic organisms, exercising influ- 
ence on neighboring healthy tissues and conveying disease 
to them. The establishing of disease from this source would 
be infinitely more marked in every case if it were not for the 
power of resistance with which healthy tissue is endowed, 
by which antibodies are produced to combat the bacteria; 
the toxic effect of the bacteria is overcome to a point of 
immunity, to which the tissues are capable of resisting, 
beyond this point it exercises an irritant effect on the tissues, 
resulting in inflammation, and organisms are able to multiply 
and dominate the tissue area affected by their presence in 
large numbers. 

The degree of immunity varies considerably according to 
the power of resistance endowed in the tissues; thus it may 
be observed that some individuals retain a considerable 
amount of local irritant in very uncleanly mouths without 
developing pyorrhoea, while others develop the disease readily 
from the slightest amount of foreign matter about the teeth. 
In this respect environment, mode of living, occupation, 
heredity and constitutional disorders undoubtedly exercise 
great influence. 

In the presence of the smallest amount of irritant in the 
gingival trough, which produces even a slight inflammation 
of the gingivus, it is possible that pathogenic bacteria are 
capable of entering the tissues and increasing in numbers, 
and although combated by the tissue-resistance to a point, 
local infection is inevitable, except there is an unusual 
immunity. It is therefore impossible to designate the stage 
at which pathogenic infection first takes place. -It is erro- 



BACTERIA 33 

neous to diagnose the disease as only starting when the gin- 
gival trough is deepened or pockets have been formed or pus 
is present. The early infection doubtless starts with the 
first slight inflammation and microorganisms begin then to 
adapt themselves to the tissues and to multiply in their 
effort to overcome immunity of the local area and to inflict 
their toxins on the tissues; from this stage onward, until 
immunity is lost and the tissues have broken down into deep 
pockets with pus, they are always present in ever-increasing 
numbers. 

If this view of the early influence of microorganisms on 
the gingival margin were more universally accepted and 
acted upon the development of the disease in its advanced 
forms would be much rarer than it is at the present time, at 
least in individuals who visit their dentists at regular 
intervals. 

A large number of different bacteria have been cultivated 
from pyorrhoea pus. Miller isolated twenty different bacteria 
from twelve cases of pyorrhoea, among which he mentions 
Staphylococcus pyogenes aureus, Staphylococcus pyogenes 
albus and Streptococcus pyogenes, "but was not able to 
determine the constant occurrence of any particular one 
which might be defined as the specific microorganism of 
pyorrhoea alveolaris." Miller's investigations appear to have 
been made from specimens taken from advanced cases, and 
in most instances he found but one kind of organism or one 
kind so predominated that the others could be left out of 
account. Later investigators describe the presence of many 
different kinds of bacteria very constantly present in the 
pus. Dr. C. P. Brown 1 found the almost constant presence 

1 New York Med. Jour., December 20, 1913. 



34 BACTERIA AND MOUTH PROTOZOA 

of six kinds of bacteria in pyorrhoea pus, namely, Bacillus 
influenzae, the streptococcus, staphylococcus, pneumococcus, 
Micrococcus catarrhalis and diphtheroid bacilli. Goadby 1 
investigated a large number of cases of the early stages of 
the disease and noted some difference in the microorganisms 
present at this stage to those found at more advanced stages; 
cultures made from them showed that the most commonly 
occurring were those corresponding to organisms of inflam- 
matory catarrh: namely, Micrococcus catarrhalis, Bacillus 
coryza segmentosa or Bacillus septus, Micrococcus pneu- 
monia? and in addition he found Bacillus necrodentalis 
(Goadby) and Micrococcus citreus granulatus (Freund). 
In later stages of the disease, when immunity of the general 
system was lowered and constitutional disturbances evident 
from absorption of toxins, the predominating organisms were 
usually staphylococci and streptococci or the pneumococci. 
Microscopic examination of films of pus which are properly 
stained reveal a large variety of microorganisms (many of 
which do not grow on culture media), pus cells, hyaline cells, 
and epithelial debris. The bacteria include the numerous 
groups of cocci, bacilli, spirochetes and streptothrix. 

MOUTH PROTOZOA. 

Entamoeba buccalis has been found in the mouth from 
time to time and described by various authors. Gross, in 
1849, described Entamoeba gingivalis, Sternberg, in 1862, 
Entamoeba buccalis, Grasse,in 1879, Amoeba dentalis, Flexner, 
in 1892, Amoeba Prowazek in 1905 Entamoeba buccalis; 
but it was not until 1914 that the researches of Chiavaro 
of Rome, and Barrett, of Philadelphia (simultaneously and 

! Proc. Royal Soc. Med. (Odontological Section) iii,. 55. 



MOUTH PROTOZOA 35 

independently conducted), established the fact that Enta- 
moeba buccalis is always present in pyorrhoea pus. The 
organism is described as measuring 6 to 30/z, with a single 
vesicular nucleus of 1.5 to 4.5/* in diameter, poor in 
chromatin, with a thick membrane. It is very mobile, con- 
stantly changing its form by thrusting out one, two or more 
lobular pseudopods in its activity and showing a clear dis- 
tinction between the endosarc and extosarc. Chiavaro 




Fig. 4. — Large oblong and medium round type entamoeba with black 
masses ingested and surrounded by nourishing vacuoles. Fixed and stained 
with ferric haematoxylin of Heidenhain. (After Chiavaro.) 



draws attention to the ingestion of bacteria by entamoeba? 
which could be seen in the protoplasm in fixed and stained 
specimens (Fig. 4). 

Chiavaro came to the conclusion that "the entamoeba has 
not a pathogenic action; on the contrary, as it feeds on 
bacteria, it is most probably an aid to the autodisinfection 
of the mouth." This view the writer is inclined to accept 
after investigating 50 cases of pyorrhoea in which amoebae 



36 BACTERIA AND MOUTH PROTOZOA 

were found in 78 per cent., and in a paper read at the Royal 
Society of Medicine, June, 1915, expressed doubts, from a 
clinical standpoint, of the pathogenic action of Entamoeba 
buccalis in pyorrhoea. Barrett and Bass and Johns, how- 
ever, pressed the claim, on clinical grounds, that Entamoeba 
buccalis being present "in a large proportion of pyorrhoea 
pockets and the disappearance of suppuration under appro- 
priate treatment by a known amcebicide, such as emetin, 
have served to justify the claim that they are the immediate 
important factor in an overwhelming number of pyorrhoea 
cases." 1 This theory has been amply disproved and the 
presence of Entamoeba buccalis in the mouth is looked upon 
as having no pathogenic influence on the disease. 

1 Barrett, M. T.: Dental Cosmos, December, 1914. 



CHAPTER III. 
PATHOLOGY OF PERIODONTAL DISEASE. 

The pathological lesion exhibited in periodontal disease 
should be studied from its very initial stage when the physio- 
logical structure and function of the component cells are 
injured by some irritant cause and stimulated to excessive 
bioplastic activity which is always hyperplastic. The com- 
ponent parts of the structure under consideration must be 
recalled — the alveolar bone, the periodontal membrane and 
overlying fibrous or mucous tissue — all richly supplied with 
bloodvessels and containing terminal cells of singularly 
degenerative and transitory nature. 

The initial pathological lesion is always instituted by an 
irritant in the gingival trough or injury to gingival tissue, 
resulting in inflammation, i. e., dilation of bloodvessels, 
acceleration of blood flow followed by retardation, exudation 
and migration of leucocytes, stasis and degenerative changes, 
with accompanying proliferative and reparative changes. 
At the very earliest stage evidence of irritation to the gin- 
gival trough is hardly perceptible and can only be deter- 
mined by clinical examination of the condition and contents 
of this space; but gradually this initial inflammation leads 
to marked congestion of the gingival fold and swelling of 
interdental papillae accompanied by inflammatory exudates. 
A stagnation area is established in which mouth organisms 
are present; they begin to adapt themselves to favorable 



as 



PATHOLOGY OF PERIODONTAL DISEASE 



conditions and produce an irritant influence on the tissues. 
The process of deposition of subgingival calculus now begins; 




Fig. 5. — d, dentine; p, calculus; /, papillary layer of the gum; z, epithe- 
lial layer; i, tissue infiltrated with leucocytes; c, normal gum; y, normal 
bone. Magnified 80 times. Description from Dr. Znamensky's 



the terminal cells of the periodontal membrane subjected 
to degenerative and proliferative changes under increased 
nutritional conditions deposit the calcareous salts from the 



PATHOLOGY OF PERIODONTAL DISEASE 



39 



blood by a process of pathological calcification much the 
same as that which governs other pathological calcifications, 



V ".>. ■■• v ' ;; ' * 






.Ifj-i 



•i 



Fig. 6. — A more advanced stage than that shown in Fig. 5. The destruc- 
tion of the epithelium has commenced at h and y. Magnified 80 times. 

"whether of the eye, the brain, the heart, the kidneys, the 
liver or the interna of arteries." 1 This deposit takes the place 



Howe: Tr. Sixth International Dental Congress. 



40 PATHOLOGY OF PERIODONTAL DISEASE 

of the insertion of the periodontal membrane into the neck 
of the tooth and is constantly added to as cells become 
destroyed and exudation becomes prolific from increased 
hyperemia of the tissues. The destruction of periodontal 
attachment and epithelial lining of the gingival fold gradually 
deepens and widens the gingival trough, into which further 
irritants are readily introduced in the shape of food debris, 
providing a suitable pabulum for the maintenance and 
increase of pathogenic microorganisms. 

The spread of inflammation to the alveolar bone sets up 
an osseous atrophy beginning at the free margin of the deli- 
cate alveolar structure into which is inserted the superficial 
fibers of the periodontal membrane; as the disease advances 
the destruction of periodontal tissue and consequent deepen- 
ing of the gingival trough a space or "pocket" is formed. 
Osteoporosis often precedes comparatively slight inflamma- 
tion of the alveolar border to a very disproportionate degree, 
hence the belief by some writers that osseous atrophy is the 
primary lesion in the disease; but in the author's opinion 
the osteoporosis and rarefying osteitis is an effect, not the 
cause, of periodontal disease. 

Up to this stage no visible pus is present, the process of 
destruction of the tissues at the local initial site is admirably 
depicted in the accompanying illustrations by Dr. Znamensky 1 
in which the calcareous deposit is seen in proximity to 
affected soft tissues. 

Gradually the process of destruction of periodontal tissue 
and adjacent alveolar bone extends with a consequent deepen- 
ing of the pocket into which accumulates destroyed epithe- 
lial cells, dead leucocytes, inflammatory exudations, food 

1 XVIIth International Congress of Medicine, London, Section XVII, 
p. 18. 



PATHOLOGY OF PERIODONTAL DISEASE 



41 



debris and the resultant formation of pus which constitutes 

pyorrhoea alveolaris. The pathological process which has 

D DO 




Fig. 7. — A, pulp cavity; B, dentine of tooth; C, hyperplasic cementum 
around apex of root; D, periodontal membrane, greatly thickened — hyper- 
plasic; E, indifferent tissue at apical region greatly increased in amount; F, 
free edge of bone of socket becoming converted into fibrous intervening 
tissue; G, bone of socket presenting earliest signs of osteoporosis; H, large 
osteoporotic space in bone of jaw filled with bone-marrow; /, bone of socket 
partially decalcified and converted into osteoid tissue; /, junction of living 
with decalcified bone; K, osteoclasts producing lacunar absorption; L, bone 
of jaw only slightly altered by disease; M, sequestrum undergoing periph- 
eral absorption; N, soft, cancellous tissue slightly changed from normal; 
0, inflammation of gum at neck of tooth. (From a drawing by Mr. A. 
Hopewell-Smith, Lancet.) 



42 PATHOLOGY OF PERIODONTAL DISEASE 

preceded the formation of pus differs in no way from the 
severe consequence resultant from its uninterrupted continu- 
ance, except in the severity which now exhibits itself in a 
marked osseous lesion. The weakened tissues become a prey 
to infection of pathogenic microorganisms, which overcome 
the defensive powers provided in the tissues by which leuco- 
cytes and tissue cells produce antibodies to combat their 
invasion. Great changes take place in the alveolar bone 
as the inflammation extends along the Haversian canals. 
Hopewell-Smith 1 describes it thus: "the bone becomes 
transformed into an osteoid tissue through loss of its calcium 
salts, then passes into an intervening fibrous tissue, and 
finally is attacked by the inflammatory exudation and cells, 
its bays and recesses become meanwhile greatly enlarged 
and filled with loose soft tissue, and the Haversian canals 
enlarged and irregular, the condition being termed osteo- 
porosis." 

These pathological changes which finally bring about the 
loosening and exfoliation of the teeth, are purely local (with 
a local irritant cause to start with), finally involving the 
entire transitory bony frame supporting the teeth ; the process 
of inflammation becomes chronic but never ceases unless 
the local irritant cause is completely removed. The rapidity 
of advance of the disease, its fluctuating severity, the variety 
of forms it apparently assumes and its intractability to 
treatment appear to be dependent chiefly on the structure 
of the alveolar bone. The degree of development and density 
of this cancellous osseous tissue has a distinct influence on 
the resistance it is capable of exerting against inflammatory 
action started in direct proximity to its most vulnerable 

1 Dental Cosmos, 1911, p. 405. 



PATHOLOGY OF PERIODONTAL DISEASE 43 

part (the margin). Examination of museum specimens 
clearly indicates that pathological changes take place more 
extensively in specimens which exhibit lack of development 
of alveolus, and that resistance to the disease is evident in 
well developed jaws. 

The present-day mode of living is liable to adversely 
affect the development of the bone around the teeth, 
which are not called upon to perform their normal func- 
tions, and as a consequence a fragile alveolar structure 
is formed about the roots of the teeth which is incapable 
of resisting attack by disease. An almost distinct form 
of pyorrhoea exists, which, if studied closely can be traced 
to this lack of development; the jaws are usually thin 
(often in keeping with a delicate osseous frame), the outer 
plate of alveolus is exceedingly fragile, consisting of a thin, 
pointed film of bone at the margin about the necks of 
the teeth; the muscles of mastication are correspondingly 
ill-developed, suggesting lack of proper masticating exercise. 
The slightest irritation to the muco-periodontal membrane 
affects this delicate osseous structure and starts osteoporosis 
which advances in great disproportion to the amount of 
inflammation present, causing a considerable loss of bony 
structure before any sign of pus is present; the overlying 
gum tissue is universally crimson to a point corresponding 
to the advancing inflammation in the osseous structure. 
Pockets of considerable depth rapidly form about such teeth, 
and they loosen very rapidly. This form of pyorrhoea is 
often attributed to constitutional disorders, but is only 
indirectly attributable to this, inasmuch as a weak osseous 
frame about the teeth is readily affected by inflammation. 

On the other hand if the alveolar process is well developed 
and the maxillary bones normal in size, osteoporosis and 



44 PATHOLOGY OF PERIODONTAL DISEASE 

rarefying osteitis of the type described is never present. 
Pyorrhoea may develop as a consequence of irritants accu- 
mulating in the gingival trough, but the progress of the dis- 
ease is slow and marked rarefying osteitis does not occur, 
until the last stage of the disease is reached. 

The disease, when accompanied with conditions of general 
disease of the osseous system, is undoubtedly influenced by 
pathological conditions peculiar to those osseous diseases, 
but those cases are comparatively rare, and have special 
significance only on the pathology of those particular cases 

The pathological reason given for the theory that perio- 
dontal disease is purely local is amply verified by compara- 
tive studies of the disease in animals. Colyer 1 states that 
in the horse "the initial lesion was shown to be a slight 
destruction of the interdental papillae, probably from the 
injurious character of the food." In cats and dogs he says 
"the explanation is that soft diet clings about the teeth, 
stagnation areas are formed, and a marginal gingivitis is 
produced." It is certainly necessary that a local irritant 
cause must be present to disturb the normal physiological 
function of the tissues and produce the initial pathological 
lesion. Talbot 2 has shown by experiment on dogs that 
pyorrhoea could not be produced by injecting pyorrhoea pus 
into healthy gum tissue, but infection occurred when tissues 
were inflamed. " The pathologic finding in these cases were 
not unlike inflammation and infection in other tissues." 

The most frequent initial irritant in periodontal disease 
in man is undoubtedly stagnation produced in the gingival 
trough as a result of modern diet. Particles of soft sticky 
food adhering to the necks of teeth produce the initial irrita- 

1 Chronic General Periodontitis, p. 46. 

2 Interstitial Gingivitis, p. 126. 



PATHOLOGY OF PERIODONTAL DISEASE 45 

tion, and start the inflammatory stagnation area which leads 
to more extensive inflammation, and ultimately to breaking 
down of the component structures of the parts involved. 

This conception of the pathology of periodontal disease 
condemns the term "pyorrhoea alveolaris" because the dis- 
ease exists in all its phases before pus is present, and the 
pus stage is only the result of continued pathological process, 
which should be recognized in the earlier stages. 

The influence of constitutional infectious diseases, such as 
syphilis, tuberculosis, actinomycosis, etc., or constitutional 
irritants, such as drugs, metal poisoning, auto-intoxication, 
is undoubtedly reflected in the intractability of periodontal 
disease, when that disease has been started by a local patho- 
logical lesion, but these cannot be said to cause the disease 
except when they are capable of producing interstitial 
gingivitis, as in the instance of drugs or metal poisoning, 
otherwise, a perfectly healthy gingivus may be maintained 
in the presence of constitutional disorders. 



CHAPTER IV. 
TOXEMIC EFFECTS OF PERIODONTAL DISEASE. 

Alimentary toxaemia due to pyorrhoea pus is one of the 
commonest effects of the disease, and, as the term implies, 
covers a very wide field. There are many toxsemic 
effects on various parts of the body which can be traced 
directly to the local infection. Microorganisms from this 
source enter the system by direct absorption into the blood 
stream at the source of infection and by swallowing of pus. 

The structure of the alveolus and the attachment of the 
teeth by periodontal membrane exposes these parts in a 
singular degree to violence, with the minimum of protection. 
Inasmuch as this is the only instance in the body where 
periosteum is exposed at the surface with little or no protec- 
tion, there being only the gingival fold and a thin epithelial 
layer overlying, it is therefore prone to injury and infection, 
and when infected, being in immediate contact with bone 
tissue, becomes a septic ulcer more violent and more toxic 
than ulcers in gastro-intestinal tracts, which have some 
detoxicating organ, like the liver, to correct and modify the 
toxins introduced from this source into the blood. Absorp- 
tion from this source is therefore direct, profuse and far- 
reaching. 

The supply of streptococci and other organisms from 
pyorrhoea when pus is swallowed passes over the tonsils and 
pharynx into the gastro-intestinal canal, where in passing 



TOXJSMIC EFFECTS OF PERIODONTAL DISEASE 47 

it often produces different stages of tonsillitis, pharyngitis, 
gastritis, intestinal inflammations, gastric erosions and 
ulcers in various parts of the alimentary tract, and appendi- 
citis. Of 150 cases recorded by Goadby, 1 42 per cent, had 
gastro-intestinal affections, 56 per cent, had rheumatic 
symptoms, peri-articular arthritis, arthritis deformans or 
fibrositis and muscular rheumatism. 

Toxins absorbed from oral sepsis are the sole cause of 
many inflammatory diseases of the eye, although the nature 
of the poison does not seem to have been discovered. Wm. 
Lang 2 has pointed out that the removal of the pyorrhoea 
source of sepsis has been sufficient to reduce inflammation 
and pain in the eyes, and asserts that "in recent cases of 
central choroiditis the lost vision quickly returns," after 
the pyorrhoea has been cured. Mr. J. B. Lawford, 3 in summing 
up the influence of oral sepsis on the eyes, says: "The 
recurrence of iridocyclitis with fresh outbreaks of pyorrhoea 
leave little room for doubt that the ocular lesions are caused 
by the septic condition of the mouth, and probably through 
the agency of toxins." 

Neurasthenia is a common result of toxic poisoning from 
oral source. The characteristic symptoms of malaise and 
fatigue precede the more marked fatigue neurosis, which is 
often accompanied by thrills and wavy feelings and also 
insomnia. Toxins carried into the blood stream account, 
in a measure, for neurasthenia; but there is also the inflam- 
matory irritant at the local site of infection, having a direct 
influence on the vasoneural circuit by which short-circuiting 
of nerve energy is brought about and the perpetual abnormal 
closure of the sensory circuits produces constant ganglionic 

1 Proceedings of Royal Society of Medicine, vi, Part I, p. 224. 

2 Ibid., p. 301. 3 Ibid., p. 124. 



48 TOXEMIC EFFECTS OF PERIODONTAL DISEASE 

discharges, resulting in fatigue of nerve energy, which is 
only relieved by rest and the removal of the irritation. The 
removal of this septic and irritating influence by the cure of 
periodontal disease in these cases has so frequently brought 
about complete change in the neurasthenic condition that 
the writer has no hesitancy in expressing his conviction 
that periodontal disease is often the sole cause of the nervous 
affection. 

The degree of infection which is likely to bring about 
toxsemic effects on the system deserves close attention. It is 
generally conceded that a large amount of sepsis in the oral 
cavity, extending over a long period, is undoubtedly a fre- 
quent cause of constitutional disorders; but observation of 
many cases which have been noted has convinced the author 
that very slight gingival infection, of comparatively short 
duration, is capable of producing the same effect. The 
reaction of the tissues by which a protective barrier is set 
up against the toxins produced by sepsis depends on the 
inherent vitality of the tissues, that is, on their functional 
activity in producing antibodies at the local site to combat 
the microorganisms — but this protection is often insufficient 
in cases of only slight infection to provide immunity against 
toxaemia, which may result when only a slight gingival affec- 
tion apparently is present without the presence of pus. 

Absorption of toxins from apparently slight pathological 
lesion of the periodontal membrane producing constitutional 
disorders identical with well known effects of extensive 
pyorrhoea alveolaris may be illustrated by instances in actual 
practice recorded in the following typical cases : 

Case I. — Mrs. G., of Oxford, aged forty years. The condi- 
tion of the gingival margin only revealed a slight gingivitis; the 
teeth were perfectly clean above the gingival margin, but in 



TOXMMIC EFFECTS OF PERIODONTAL DISEASE 49 

the gingival trough, clinging to the necks of the teeth, a rough 
granular deposit of subgingival calculus was detected and 
the bleeding from the gingival fold was profuse. There were 
no pockets, only a deepening of the trough, which also con- 
tained some food debris, no pus on pressure. Constitutional 
disorders complained of were malaise, rheumatic pains in 
the knee- and shoulder-joints and headaches. The patient 
was in the habit of taking her own temperature, which she 
said was usually 100° to 101° at night, except for a few days 
after visiting her dentist and "having a good clean up." 
Her dentist, who referred her to me, rightly said there was 
no "pyorrhoea;" her medical adviser could find no cause for 
temperature and other symptoms. Treatment consisted in 
thoroughly removing all calcareous deposits and electro- 
sterilization of the gingival trough with zinc ions. Tempera- 
ture disappeared after the third treatment, malaise and 
headaches in a fortnight and every trace of rheumatism in a 
month. Perfect health has followed ever since. 

Case II. — Mrs. B., aged forty-two years, seemed to have 
perfect condition of gums and teeth, no redness or bleeding 
until an instrument was passed into the gingival trough; no 
pus or deep pockets. The superior first premolars had been 
extracted "to make room" (Fig. 8). This had upset the 
normal balance of the articulation producing undue stress 
on the superior lateral incisors and second molars resulting 
in chronic irritation of the periodontal membrane, some 
rarefying osteitis about the roots of these teeth, and slight 
loosening of the teeth. A crust of subgingival calculus 
existed on all the teeth and in larger quantities about the 
loosened teeth. Radiograph (Fig. 9) shows the condition 
of the alveolus about the incisors. The patient complained 
of malaise and rheumatic pains in the joints. Removing 
4 



50 TOXEMIC EFFECTS OF PERIODONTAL DISEASE 

the calculus and relieving undue stress, with a course of 
electro-sterilization with zinc and iodin ions, particularly 




Fig. 8. — -Showing abnormal occlusion due to extraction of superior first 
premolars. 



about the loosened teeth, produced a complete cure of rheu- 
matism in six weeks, and there has been no recurrence of 
constitutional symptoms. 




Fig. 9. — -Radiograph of superior incisors. 



Very severe rheumatoid arthritis may be brought on by 
apparently slight periodontal disease in what may be 



TOXEMIC EFFECTS OF PERIODONTAL DISEASE 51 

described as well kept mouths, as illustrated by the following- 
case, which was reported by the writer at the Royal Society 
of Medicine, Odontological Section, July, 1918. 

Case III. — Mr. B., aged about forty-five years, consulted 
me on June 28, 1917. He was unable to walk and could only 
move about with assistance and the aid of crutches; his 
knee-joints were very much bent and perfectly rigid. He had 
been in that condition for a considerable time and informed 
me that the doctors in attendance attributed his arthritis 
to septic absorption, the only source of which was his mouth, 
and that there was a question as to the advisability of 
extracting all his teeth, which were perfectly sound and not 
loose. He had been treated for pyorrhoea by vaccine therapy, 
the predominating organism being the streptococcus from 
which the vaccine was prepared; but this appeared to have 
had very little effect on his arthritis, although the state of 
his gums seemed to have been much improved. 

His teeth were perfectly clean as far as the gingival border, 
the gums looked fairly healthy, there being only a fringe of 
redness about the lower incisors and a purple hue about the 
lingual surfaces of the molars. The patient worried over his 
condition a good deal; he brushed his teeth several times a 
day and used peroxide of hydrogen freely. There was no 
visible pus anywhere. Examination of the gingival trough 
revealed the true state of things. There was a hard brown 
crust of subgingival calculus encircling the roots of the teeth 
from which the periodontal membrane had receded, forming 
shallow pockets. These pockets were singularly free from 
food debris. The irritant here was the calculus, which had 
kept the gingival fold and periodontal membrane in a state 
of inflammation, as was evident from the bleeding, which 
occurred when an instrument was passed into the trough. 



52 TOXEMIC EFFECTS OF PERIODONTAL DISEASE 

Tissues in this condition become readily infected, the toxins 
passing into the system by direct absorption into the circu- 
lation. 

Treatment consisted in removing every particle of calculus 
and polishing the root surfaces. At each sitting ionization 
of the gingival trough and alveolus was carried out with 
zinc ions, the patient being a good electrical subject, a cur- 
rent of 5 to 10 ma. was tolerated and the tissues yielded 
immediately to the treatment. 

On August 10 he was discharged, every sign of inflamma- 
tion in the gingival trough having disappeared. Three 
months later the pockets were examined and found to be in 
the same healthy state. A decided improvement had taken 
place in the rheumatoid affection; the patient could walk 
across the room without crutches; although his knees were 
still bent and stiff, he nevertheless expressed his conviction 
that he was progressing favorably. On June 10, 1918, 
when he was last seen (ten months after treatment), the 
gingival trough was perfectly healthy; he had long since 
discarded the use of crutches, his knees were almost normal 
in shape, only a slight stiffness remaining; he was able to 
walk long distances and had resumed his occupation as an 
engineer. He had had no other treatment since his course 
of ionization; had simply kept his teeth clean, using a benzoic 
acid and thymol wash on the brush twice daily. 
* There can be no doubt that the rheumatoid arthritis was 
caused by this apparently slight septic inflammation of the 
gingival trough, and a cure was effected by removing the 
local irritant cause, and at the same time sterilizing the 
affected tissues by zinc ionization — both being necessary 
in my opinion. 

Passing to the effects produced by oral sepsis in advanced 



TOXEMIC EFFECTS OF PERIODONTAL DISEASE 53 

cases of periodontal disease, when in addition to direct 
absorption of toxins at the site of local infection large quan- 
tities of pus pass into the stomach of what may be an already 
weakened constitution, the presence of a great and constant 
supply of organisms tends to destroy the gastric defence and 
weaken the tissues, making it possible for organisms to pass 
into the intestinal tract. Under general weakened conditions 
of the intestines they are able to enter the system, poisoning 
the tissue cells by their toxins, and bringing about structural 
changes and disease. 

The germs associated with oral sepsis vary and systemic 
conditions vary, so that the absorption of toxins produces 
a wide variety of diseases — in some arthritis, in others 
anemia, in others neuritis and so on, according to favorable 
conditions for inhibition of the microbes. 

The pathological significance of oral sepsis has often led 
medical diagnosis astray and caution is necessary in deciding 
that other diseases are caused by mouth bacteria, which may 
not be the direct source of infection; nevertheless, the oral 
condition should always be eliminated without too definite 
promise of eradication of the disease. 

Sufficient importance does not appear to have been placed 
on the fact that spirochetes are largely associated with 
pyorrhoea; apart from the knowledge that they are usually 
present, the subject does not seem to have engaged the 
serious consideration of dental pathologists in relation to 
periodontal and general disease. Moritz has described the 
presence of spirochetes in the tissues and bone-marrow in a 
case of anemia. J. G. Thomson and Dr. Thomson 1 have 
made extensive investigations of this subject and they state 

1 Beck, Marcus: Laboratory Reports, i, 65. 



54 TOXEMIC EFFECTS OF PERIODONTAL DISEASE 

that " If medical men in this country would begin a systematic 
examination of the mouths of patients, we have not the 
slightest doubt that, like ourselves, they would be astonished 
to find millions of spirochetes in small scrapings from the 
alveolar margin. These in many cases are too numerous, 
even if they are considered only saprophytes, to be associated 
with good health. They must be elaborating toxins of a 
peculiar character and they must also assist in the general 
destruction of the tissues in the alveolar margin." 

It is significant that in trench mouth, which was brought 
into prominence during the great European War, spirochetes 
are found to predominate so greatly that they are generally 
accounted responsible for this pathological condition ; further, 
the systemic changes which accompany the disease clearly 
indicate that the organism finds its way into the tissues 
and alimentary tract and finally becomes so altered as to be 
able to live in the blood stream. The enormous increase 
in numbers in cases of trench mouth, pyorrhoea alveolaris, 
alveolar abscess and Vincent's angina must produce toxins 
detrimental to health and in a great measure be responsible 
for the constitutional disturbances usually present in these 
diseases. 



CHAPTER V. 
EARLY DIAGNOSIS OF PERIODONTAL DISEASES. 

Too much stress cannot be placed on the importance of 
early diagnosis of periodontal disease, the incipient stage 
of which is far too often overlooked so that the disease, which 
has its origin in the gingival trough, is allowed to progress 
beyond the early infection of periodontal tissues, before it is 
recognized as of any importance. The gingival margins, 
when normal, are of tough bloodless tissue, of a clear pink 
hue, capable of resisting considerable pressure from tough 
foods during mastication without discomfort; redness, ten- 
derness, or bleeding are clearly indicative of beginning inflam- 
mation, the causes of which should be diagnosed before it 
reaches the stage of acute congestion. Should any signs of 
abnormality be present, a minute examination of the gingival 
trough should be instituted, when invariably some foreign 
substance will be revealed, which accounts for this stagnation 
area in the tissues leading up to what will result in gradual 
deepening of the trough and breaking down of the thin 
epithelial layer of tissue overlying the poorly protected 
bony structure immediately underneath. The utmost im- 
portance should be placed on these signs, as the beginning 
of disease, and proper treatment advocated to avert the 
consequences of periodontal diseases, which almost invariably 
follow. 

Passing from this early stage, symptoms are more easily 



56 EARLY DIAGNOSIS OF PERIODONTAL DISEASES 

diagnosed, but even then they are far too often looked upon 
as a gingivitis with no direct bearing on ultimate periodontal 
disease. The heaping up of gum tissue, congestion with free 
bleeding on brushing or touching the gums (there being no 
visible pus) should be included in the possibility of septic 
infection having started in an unhealthy gingivus, in which a 
deepened gingival trough and damaged periodontal attach- 
ments, under influence of local irritants, will continue to 
break down until pus supervenes. 

In well kept dentures, where daily hygienic measures have 
been taken, often none of the hyperemic symptoms are 
present, still a wasting of the gum tissue is evident with 
absorption of the alveolar bone, elongated necks of teeth are 



Fig. 10. — -Examining scalers. 

present with disappearance of interdental papilla?. In these 
cases examination of the roots of teeth made by passing a 
delicate hooked scale (Fig. 10) parallel with the long axis of 
the tooth, and scraping the surfaces under the thin taut 
overlying gum, will reveal a granular deposit of calcareoas 
salts, firmly adherent to the surfaces of the roots. Often 
this irritant is only to be found on the surfaces of approxi- 
mating roots in the form of sharp granules (Fig. 11) readily 
discernible by a scaler but often in the form of a dark hard 
crust, smooth on the surface and most tenacious, requiring 
considerable force to detach even a small bit of it. This 
condition should be recognized as slowly progressing perio- 
dontal disease, in which pathogenic microorganisms play 



EARLY DIAGNOSIS OF PERIODONTAL DISEASES 57 

an important part. It is not caused by overbrushing as 
often designated. 

Acute and chronic periodontal disease (pyorrhoea alveo- 
laris) which is unmistakable, in which deep pockets are 
established, filled with decomposing food, epithelial debris 
and pus, with great loss of bony tissue and loosening of teeth, 
is but a continuation of the early stages described, which 
have progressed unrecognized by patient (and often by 
dentist) for many years before reaching the climax, which 
brings it into prominence. 




Fig. 11.— SC, subgingival calculus. 



The calcareous deposit referred to so far is by no means 
the sole diagnostic feature, many other causes require diag- 
nosing, some of which are of a subtle nature requiring 
infinite care to recognize. Among these, faulty occlusion 
and undue stress are of importance. The common practice 
of extracting premolars or first molars to relieve "over- 
crowding of the arch" in the young, almost invariably leads 
to disturbing the balance in certain areas of the denture, as 
well as the creation of abnormal spaces, which results in time 
in periodontal disease. The loss of teeth from caries, usually 
the molars in either maxilla or mandible, especially when 
this is unilateral, and their place is not supplied with artifi- 



58 EARLY DIAGNOSIS OF PERIODONTAL DISEASES 

cial substitutes, is a fruitful means of producing undue stress 
on other parts of the denture and supplying an irritant to 
the osseous frame and fibrous attachments of the teeth, by 
which periodontal disease can be maintained. 

The palatal and lingual surfaces of the gingivus are fre- 
quently the sites of infection, when artificial substitutes for 
teeth impinge on these parts; most frequently is this notice- 
able in the mandible when the molars are lost and a plate is 




Fig. 12. — Badly constructed shell crowns. 

made to rest on the lingual surfaces of the incisors, absorp- 
tion of the alveolus at the back allows the plate to settle down 
snugly on the front portion and provides a constant irritant 
acting injuriously on the gingivus and underlying bone. No 
form of treatment will succeed while this exists. 

The faultily constructed shell crowns or banded crowns, 
where a space exists between the free edge of the metal and 
the root is an undoubted source of infection, which requires 
careful investigation, not that every crown of this description 



EARLY DIAGNOSIS OF PERIODONTAL DISEASES 59 

is necessarily a cause of infection, far from it, but it should 
be determined whether the free edge of metal is so well 
adapted to the circumference of root as to preclude any 
irritating influence on the gingival fold, either directly by 
pressure, or indirectly by retaining foreign matter in the 
space. Should congestion about the edge of a crown be 
present, it is necessary to determine whether faulty construc- 
tion is responsible, or merely the spreading of infection from 
adjacent parts, accompanied by a general irritant cause, 
such as calculus and stagnant food. The same applies to 
bridges and all forms of fixed appliances. It is often necessary 
to condemn these as a source of periodontal disease; but when 
properly constructed, in the mouths of patients who are 
capable of carrying out proper daily hygienic methods, there 
is no reason why they should be condemned at sight, even 
when pyorrhcea symptoms are present in other parts of the 
mouth; and here it becomes necessary to determine the true 
cause of any inflammatory symptoms present and decide by 
accurate diagnosis the advisability of retaining a fixed appli- 
ance in the face of existing periodontal disease when treat- 
ment is to be undertaken. 

In the undertaking of treatment of periodontal disease 
it is of utmost importance to recognize the irritating nature 
of overhanging fillings, and faulty contour of fillings (Fig. 13). 
This source of irritation, if not removed, will cause failure to 
preclude anything like permanent results by treatment, and 
recurrence, even after apparently good results, is unavoid- 
able at those parts. Here radiography is invaluable in 
arriving at a sure diagnosis. A slight ledge may be detected 
by this means, which entirely escapes the exploring instru- 
ment. Inversely the existence of caries at or under the gum 
level provides an irritant cause, which requires detection, 



60 EARLY DIAGNOSIS OF PERIODONTAL DISEASES 

not only does the sharp edge of a cavity in contact with the 
gingival tissue produce inflammation, but the contained 
debris of decay and decomposed food provide a perfect 




FiCx. 13.— Faulty filling. 



pabulum, on which microorganisms thrive and keep up the 
source of infection. 

Radiographs should be procured of all advanced cases of 
periodontal disease, without which it is difficult to diagnose 
the extent of the disease. It is important to determine the 




Fig. 14. — Imperfect crown causing periodontal disease. 



amount of destruction of bone, the depth of pockets, the 
condition of the bone, the presence of irritants such as sub- 
gingival calculus, faulty fillings or crowns (Fig. 14). On the 



EARLY DIAGNOSIS OF PERIODONTAL DISEASES 61 

condition revealed a diagnosis can be made of the teeth which 
should be extracted. Many teeth which clinically appear 
hopelessly involved will present in the radiograph a healthy 




Fig. 15. — Enlarged sockets due to undue stress, with well defined linea dura. 

alveolus, with a well-defined linea dura about sockets, which 
are enlarged in consequence of undue stress. Such teeth 
can frequently be saved. 




Fig. 16. — Subgingival calculus on roots. 



The presence of subgingival calculus is readily revealed 
when it exists on a surface of the tooth forming a shadow by 
the rays in the radiogram (Fig. 16), and when seen is usually 
of the hard dark variety, which is most difficult to remove. 



62 EARLY DIAGNOSIS OF PERIODONTAL DISEASES 

Faulty fillings and defective crown work are readily 
detected, and the condition of the bone in the latter is a guide 
to determining the advisability of recrowning in the presence 
of existing periodontal disease. 




Valuable diagnostic information is afforded by correct 
reading of the condition of the bone, as shown in radiographs, 
by which the degree of absorption and rarefying osteitis can 
be accurately judged. If a perfectly defined linea dura is 
shown it would exclude to a great extent the probability of 



Fig. 18. 




nea dura. 



osteoporosis and infiltration of microorganisms deep into the 
bony structure, but if every trace of the linea dura has 
disappeared the bony structure presents a homogeneous 
radiolucent appearance, extensive rarefying osteitis with 
general bacterial infection can be diagnosed, which justifies 



EARLY DIAGNOSIS OF PERIODONTAL DISEASES 63 

the opinion of long standing periodontal disease of a serious 
character. So, too, an enlarged socket about the root of a 
tooth, where bony tissue has not absorbed to a great extent 




Fig. 19. — General rarefying osteitis. 

points to the possibility of undue stress causing movement 
of the tooth in its socket, and often gives the clue to this 
obscure cause of irritation and loosening of the tooth (Fig. 20) . 
Diagnosis of the condition with relation to other existing 
pathological lesions, when it becomes necessary to determine 
the advisability of retaining teeth in spite of suspected toxic 




Fig. 20. — Linea dura affected by movement of teeth in their sockets. 



influence of organisms on the system, requires precise judg- 
ment of the extent of the disease and as to the possibilityof 
retaining certain teeth in a functional and healthy condition 



64 EARLY DIAGNOSIS OF PERIODONTAL DISEASES 

after the most careful treatment. It must be borne in mind 
that conservative treatment is aided by the removing of the 
septic source, by improvement in the general health and with 
it the tssue at the local site of infection, so that the necessity 
for extracting every tooth from which pus exudes or may be 
expressed from its socket, does not apply as a hard and fast 
rule, but teeth, which after treatment cannot possibly be 
kept clean by the daily hygienic efforts of the patient, should 
at once be extracted, such as molars, when the alveolar bone 
has absorbed to such an extent that the bifurcation of roots 
is exposed, forming a receptacle for lodgment of food. Teeth 
which have pockets extending to the apices, when, on passing 
a probe, necrotic condition of the root can be felt, should be 
extracted. 

Dead teeth, with chronic apical abscesses, are more to be 
feared in relation to constitutional disorders than the worst 
pyorrhoea conditions, and no tooth should be retained under 
those circumstances, unless the operator is convinced of a 
radical and speedy cure of the lesion by surgical methods. 

In the molar region, advanced pyorrhoea, with deep pockets 
between the teeth, which, if the disease is checked by treat- 
ment, is liable to recurrence, it being beyond the patient to 
keep the space clean, and in view of toxemic effects, the 
extraction of the middle tooth, that is the second molar, often 
checks the disease about the two adjoining teeth, conserving 
those without fear of a potential source of infection. 

In general it should be determined at the very outset what 
sources of infection exist which cannot be totally eliminated 
by treatment and proper after-care, and these should be 
removed at once, whether they be in the nature of crowns 
or bridges or hopelessly involved teeth, for fresh attacks 
aggravate the pathological lesions in other parts of the body, 
which do not then respond so readily to treatment. 



CHAPTER VI. 
TREATMENT OF PERIODONTAL DISEASE. 

The treatment of the disease in this work is based on the 
etiology and pathology given, and definite lines are pursued 
systematizing the modus operandi, details of which will be 
gone into. 

For convenience of description, the different stages of perio- 
dontal disease are here classified as follows: 

1. Incipient infection of the gingival trough. 

2. Septic infection of the gingival trough without suppura- 
tion. 

3. Chronic septic infection of the periodontal membrane 
without visible suppuration — "dry pyorrhea." 

4. Acute septic infection of the gums and periodontal 
membrane without visible pus. 

5. Chronic periodontal disease with pus. "Pyorrhoea 
alveolaris." 

1. Treatment of Incipient Infection of the Gingival Trough. 
— Special reference has been made to this stage of periodontal 
disease in writing on etiology, pathology and diagnosis, with 
the intention of emphasizing the importance of preventing 
the development of pyorrhoea alveolaris by the adoption of 
simple methods of treatment. Prior to the stage requiring any 
treatment, a good deal can be accomplished by recognizing 
existing conditions, which are likely to promote periodontal 
disease in later life, and by advising parents what to do. 



66 TREATMENT OF PERIODONTAL DISEASE 

In this respect it is of course necessary to obtain early control 
of the child. Such conditions as poor development of the 
oral structures, due to modern changes in natural and primi- 
tive environment, and absence of normal functional activity 
of the muscles of mastication, due to dietetic arrangements 
of modern life. 

Mothers should be advised that soft pappy foods of starchy 
character should be avoided, and a certain amount of fibrous 
hard food and fresh fruit introduced into the diet, following 
out the principles laid down by Dr. Sim Wallace, 1 Dr. Harry 
Campbell and others. Mouth-breathing and adenoids should 
be attended to. Irregularities of the teeth can often be easily 
rectified by early expansion of the arches, as pointed out by 
Dr. Northcroft. Intelligent training of the child in proper 
hygienic methods should be undertaken. All these will do 
much to prevent the development of periodontal disease. 

When incipient infection of the gingival tissues has 
already been established, whether in children or adults, 
treatment consists in removing every particle of irritant on 
the tooth surfaces and in the gingival trough, and polishing 
these surfaces to the highest state of perfection. The gin- 
gival trough if congested, should then be treated by electro- 
sterilization. A platinum electrode should be wrapped with 
a few shreds of cotton-wool, saturated with a 10 per cent, 
aqueous solution of tincture of iodin, this should be passed 
into the gingival trough and the current gradually turned on 
from the negative pole, the patient holding the positive 
electrode; 1 or 2 m.a. current should be passed while the 
operator slowly moves the electrode in perfect contact 
around the necks of the affected teeth with a wiping motion 

1 Modern Dietetics in the Causation of Disease. 



SEPTIC INFECTION OF THE GINGIVAL TROUGH 67 

of the instrument, which will medicate the gingival trough, 
as well as remove any particles of debris which may remain 
after the polishing process. This treatment should be carried 
out wherever any redness or inflammation of the gingival 
border exists; a single treatment will often be sufficient to 
restore the gingivus to a normal condition, but in case inflam- 
mation persists in any isolated part, the process should be 
repeated there, after further cleansing and polishing pre- 
cautions have been taken. The gingival trough once enlarged 
by the entrance of foreign substances is liable to recurrence 
of the trouble, and the patient should be warned that in 
future any bleeding of the gums during brushing is an indica- 
tion of recurrence, when treatment will again be necessary. 
Advising the use of fresh fruit after the last meal of the day, 
especially biting into an apple, is one of the potent means of 
cleansing the necks of the teeth from sticky carbohydrate 
foods, which comprise the chief danger in incipient perio- 
dontal affection. 

2. Septic Infection of the Gingival Trough without Suppura- 
tion. — This stage of periodontal disease follows sharply on 
the preceding, and is universally looked upon as simple gingi- 
vitis. Congestion of the gingivus is marked, with loosening 
of the gingival fold, and deepening of the gingival trough, 
from which bleeding readily occurs on pressure. A process 
of breaking down of the gingival fold, the alveolar bone and 
superficial fibers of periodontal tissue is established, and 
although no pus is present, pathogenic organisms inhabit 
the tissues, which are in a condition to facilitate their growth 
and maintenance. 

Examination of the necks of the teeth will invariably 
disclose irritants in the form of calcareous deposits and 
stagnant food. Treatment consists in thorough instrumenta- 



68 TREATMENT OF PERIODONTAL DISEASE 

tion, removing every particle of foreign substance and polish- 
ing the surfaces of the teeth. Bleeding and tenderness of 
the gums will often interfere with accomplishing this end 
satisfactorily at the first operation, but ionization should 
be carried out then, and the case seen again in a few days, 
when invariably marked improvement will be noted, and 
the completion of instrumentation and polishing facilitated, 
Ionization with zinc ions should be carried out by passing a 




Fig. 21. — Progressing periodontal disease. 

spear-shaped zinc electrode of large enough size to readily pass 
into the gingival trough and wound at the point with a few 
shreds of cotton-wool saturated with 3 per cent, zinc chloride, 
the electrode should be steadily held in position, the patient 
holding the indifferent electrode. The current from the 
positive pole should then be turned on gradually, with the 
object of passing 2 or 3 ma. at least, if this amount can be 
tolerated. The electrode should be moved very slowly, in 
perfect contact around the necks of the teeth with a wiping 



INFECTION OF THE PERIODONTAL MEMBRANE 69 

motion, taking about half a minute to pass from interspace 
to interspace on the outer surface of each tooth, but here 
discretion must be exercised — parts obviously worse require 
more time at the expense of parts less affected. The saliva 
should be kept away with cotton swabs, and the zinc chloride 
replenished from time to time during the operation, turning 
off the current each time before removing the electrode. 

The case should not be discharged until it has been ascer- 
tained that all inflammation has completely subsided, and the 
gums have resumed their normal appearance and toughness, 
reestablishing nature's barrier to the introduction of food 
debris into the gingival trough. The patient should be care- 
fully instructed in an effective method of daily hygiene of 
the mouth, it being certain that the cause of the trouble is 
attributable to ignorance or neglect. 

3. Chronic Septic Infection of the Periodontal Membrane 
without Visible Suppuration — "Dry Pyorrhoea." — This phase 
of the disease, which has been described from etiological and 
pathological standpoints occurs in well kept mouths, and 
presents many difficulties in treatment, principally on account 
of the subtle, slowly progressive nature of the affection. 
The disappearing interdental papillae and taut wasted gums 
resting on exposed necks of teeth, which may be perfectly 
polished as far as the gingival border, effectively conceals an 
etiological factor in the form of calcareous deposits closely 
adherent to the roots of the teeth beneath the gums. This 
irritant takes on various forms, from hard sharp nodules to a 
finely granular layer. The treatment, to be effective, imposes 
on the operator most delicate and exacting instrumentation. 
Thin, sharp, hook-shaped scalers, with rigid shafts, should 
be passed between the gum and tooth surface to the bottom 
of the gingival trough, parallel with the long axis of the tooth, 



70 



TREATMENT OF PERIODONTAL DISEASE 



and with a hooking or rather planing motion, scrape oft' or 
plane off every particle of foreign matter, erring on the side 
of removing a thin layer of cementum rather than leaving any 
deposit adhering to the tooth, considerable force being often 
necessary to accomplish this. The author's set of scalers 
if well made with small planing blades are very effective in 
carrying out this planing of the roots. Further polishing of 
the root surface should be effected with thin wood points 
and pulverized pumice made into a paste with 20 per cent, 
aromatic sulphuric acid. In addition stiff cup-shaped brushes 



I 




Fig. 22. — Sturridge's scalers. 



used with the pumice paste assist in removing tartar and 
polishing the surfaces about the gingival border. 

Instrumentation and polishing having been thoroughly 
carried out, it remains to deal with the pathogenic micro- 
organisms, which constitute an important etiological factor. 
A thin platinum or zinc electrode should be wrapped with a 
few shreds of cotton-wool saturated with 3 per cent, zinc 
chloride and passed into the gingival trough, the current 
from the positive pole turned on gradually, the patient hold- 
ing the negative electrode. If the teeth are very sensitive 



INFECTION OF THE PERIODONTAL MEMBRANE 71 

0.5 m.a. current may be all that will be tolerated in the incisor 
region, but the molar region may admit of considerably more 
current — 2 to 5 m.a. The electrode should be slowly moved 
parallel with the long axis of the tooth around the neck, with 
the object of imparting a sufficient dose of ions to sterilize the 
tissues. In areas where the tissues are much wasted and very 
thin, the time required to effectively impregnate them with 
ions is very much less than in thicker areas like between the 
molars; one quarter of a minute to half a minute should be 
occupied in moving the electrode about the neck of a tooth, 
varying the time in direct ratio to the thickness of the tissue 
and current strength in use, that is, if the tissues are very 
thin and 3 m»a. is in use, time required will be one-third that 
if only 1 m.a. is tolerated. Similarly in thicker tissues the 
same current strength will require more time to secure proper 
depth of penetration of ions. 

The number of treatments required depends upon the 
severity of the case and the cm-rent strength available. 
Three the first week, two the second and once a week after, 
until every sign of inflammation about the gingivus has dis- 
appeared, gives some idea of the course that should be pur- 
sued. Fetid odor is often the only symptom complained of 
by the patient, until this disappears entirely the treatment 
should be vigorously continued every second day with as 
strong a current as possible and extended time, in any par- 
ticular region from which the patient locates this symptom; 
the location is usually between the molars. 

Restoration of lost bone and gum tissue cannot be expected 
in these cases, the arresting of progress of the disease is all 
that can be accomplished, the object of ionization being to 
overcome infection by pathogenic microorganisms, which 
have established themselves in the weakened tissues. The 



72 TREATMENT OF PERIODONTAL DISEASE 

chronic aspect of the disease affords the opportunity to 
nature's barrier to prevent ingress of organisms into the deep 
structure of alveolus; the slow inflammatory process stimulates 
deposition of bone salts and builds up a thickened nodular 
structure of osseous tissue about the roots of the teeth, elimi- 
nating the rarefying osteitis present in acute forms of the dis- 
ease, so that the bone which has been attacked on that surface 
in direct contact with infection from without is dense and 




Fig. 23.- — Chronic periodontal disease. 



capable of rigid support of teeth which have lost one- third 
or even a half of their alveolar border. Fig. 23, a radio- 
graph of chronic periodontal disease, shows thickened heavy 
bone about the roots with extra heavy linea dura and strong 
bone forming the floor of the interspaces. Compare this with 
(Fig. 24) a radiograph of acute periodontal disease. The 
rarefied bone with loss of linea dura is very marked. 

This form of periodontoclasia frequently attacks otherwise 
perfect dentures, and in undertaking the treatment ioniza- 



INFECTION OF THE PERIODONTAL MEMBRANE 78 

tion should not be relied on altogether. It is useful in dealing 
with the infection of the tissues, but great care should be 
exercised in discovering the other factors responsible for the 
condition. One of these (the most constant) is failure to 
carry out proper daily hygienic methods of cleaning, despite 
praiseworthy efforts, often the teeth are overbrushed on the 
outer surfaces, while the palatal and lingual aspects are 
neglected, and the interspaces never touched. The daily 




.\onte periodontal disease. 



cleansing of the interspaces with silk should be insisted on 
and a suitable antiseptic wash to be used on the brush con- 
stitutes a part of the after-management of the case, which is 
incumbent on the patient. During the course of treatment 
should the patient not comply with instructions, and should 
sticky particles of food still be found adhering anywhere, 
attention should be called to it and the importance of keeping 
it away dilated upon. The presence of mouth protozoa in 
abundance would suggest the prescribing vin. ipecac, a few 



74 TREATMENT OF PERIODONTAL DISEASE 

drops on the wet brush to be used once a day for a few months, 
alternating this with a benzoic acid and thymol wash, also 
to be used on the brush once a day. Every other etiological 
factor having been carefully eliminated, and the gingival 
trough restored to normal, it will be safe to conclude that the 
progress of the disease has been checked, and the case should 
be dismissed for three months, when it should be seen and 
close scrutiny of the condition of the gingival trough made. 
The future management of the case must depend on the con- 
dition which now presents, if the tissues have been able to 
resist further infection (which may be determined by the 
absence of bleeding on passing an instrument under the 
gingival border) the success of the treatment may be antici- 
pated, and the case dismissed for six months, after which a 
thorough clean up and a single treatment by ionic medica- 
tion twice a year will suffice to keep the denture from further 
infection. 

4. Acute Septic Infection of Gums and Periodontal Membrane 
without Visible Pus. — In treating this phase of periodontal 
disease it will be well to bear in mind the local etiological 
peculiarities which are accountable, and pathological course 
which any tissue of the body would take, were an irritant 
thrust into it and kept there, especially if that tissue were 
bathed in a septic fluid. 

The disease is marked by congestion of the gums, either 
generally or in isolated areas, the papillae are enlarged and 
heaped up between the teeth in loose tags, which bleed 
freely when touched, and the gingival trough is deepened 
by the loss of dental ligament. This stage is a continuation 
of the second stage described, and is marked by greater 
stagnation areas and more accumulation of foreign substances 
or some irritant cause of longer duration. 



SEPTIC INFECTION OF PERIODONTAL MEMBRANE 75 

Treatment should be based on accurate conception of the 
etiological factors responsible. The teeth should be examined 
carefully, and the cause determined. In young subjects it is 
often associated with mouth-breathing, adenoids, imperfect 
masticating functions, use of soft pappy foods or neglect of 
proper hygienic methods. In adults the principle cause is 
irritants in the gingival trough — calculus, food debris, some 
mechanical irritant, such as ill-fitting crowns, imperfect 
marginal edge of a filling, pressure from a dentine, extraction 
of premolars or first molars for regulating, creating spaces, 
etc. Whatever the cause it should be the aim to remove it. 
Careful instrumentation and polishing of the root surfaces 
is always necessary. Copious bleeding usually results at 
first, but subsides, and swelling decreases after the first 
instrumentation. In case of sloughing of the marginal edges 
of interdental papillae, which creates a painful condition, 
ionization with 2 per cent, silver nitrate and a weak current 
relieves this condition. 

Electro-sterilization of the gingival trough should be carried 
out at intervals of every three days, when further instrumen- 
tation and polishing are also necessary. A zinc electrode 
wound with a few shreds of cotton-wool and saturated with 3 
per cent, zinc chloride should be used to slowly wipe out the 
gingival trough with 2 or 3 m.a. current, keeping the electrode 
in good contact with the tissues while moving it, tinning 
off the current when necessary to replenish fresh wool and 
more solution when bleeding from the tissues interferes ; two 
or three such treatments with zinc, at intervals specified, fol- 
lowed by two with iodine, will often be sufficient to produce 
healthy reaction of the gums. 

As soon as the use of a stiff brush is possible the patient 
should be instructed in a useful hygienic method with den- 



76 TREATMENT OF PERIODONTAL DISEASE 

tifrice and an antiseptic lotion on the brush. Ionic medica- 
tion should be repeated at intervals until every trace of 
inflammation has disappeared, which will not occur if any 
irritant is left in the gingival trough or in contact with the 
gingival border. Patients should be warned that this condi- 
tion of gingivitis is the forerunner of pyorrhoea alveolaris, 
and is liable to speedy recurrence if strict attention is not 
paid to daily hygiene. This stage of periodontal disease 
offers great scope for prevention of pyorrhoea alveolaris; 
patients coming under observation frequently exhibit essen- 
tial factors leading to more serious stages of disease, which 
if recognized and removed forestalls its ultimate inevitable 
development. The existence of loss of balance in the articu- 
lation, particularly in young subjects, where, for example, 
the loss of a first molar not only results in elongation of the 
opposing tooth, but the creation of spaces at the adjoining 
teeth by their tilting toward the vacant space, and the 
creation of undue stress on certain teeth called upon to 
undertake extra work. Judicious replacing of such a loss 
might in itself alone prevent the development of pyorrhoea in 
a wide area of the denture. The loss of several molars, 
either maxillary or mandibular, which are not replaced by 
artificial substitutes, invariably creates undue stress on the 
anterior teeth, which in time produces the worst form of 
rarefying osteitis and pyorrhoea. Superior protrusion and 
postnormal occlusion in adults often result in the lower 
incisors occluding on the gums, providing an irritant cause 
of periodontal disease. The grinding of the surfaces of the 
lower incisors relieves this and prevents the development of 
disease at this site. In a word, every existing irritant to 
gums or roots of teeth should be recognized and treated in 
the early stages with a view to establishing a normal and 
functional denture. 



PYORRHCEA ALVEOLARIS 



77 



5. Chronic Periodontal Disease, with Pus. "Pyorrhoea Alveo- 
laris." — The treatment of pyorrhoea alveolaris, like other 
preceding stages of periodontal disease, should be based on a 
clear conception of the various etiological factors. So varied 
are these, and often so subtle, that the greatest difficulty is 
presented in detecting the real exciting cause. Detailed 
description of the etiological factors has been chronicled in 
another part of this work, and may be summed up under 
two headings — irritants and microorganisms. 



Fig. 2.5.— Di 




:/aleulus alone. 



The clinical aspect of cases of pyorrhoea is usually convinc- 
ing at a glance, but radiographs of the condition of the alveo- 
lus should be procured to determine the extent of rarefaction 
of the bone, as well as to reveal such exciting causes as faulty 
fillings or crowns, and also the depth of pockets. Much 
useful diagnostic information can be deduced from the study 
of radiographs, which often serve the purpose of determining 
at once the degree of virulence of the disease, and the possi- 
bility of dealing successfully with it. As a rule the encroach- 
ment of subgingival calculus alone causes destruction of the 
marginal edge of alveolus, and leaves an abnormally blunt 
appearance of the bone between the teeth, the linea dura 
being well defined. 



78 



TREATMENT OF PERIODONTAL DISEASE 



In cases of distortion of normal occlusion, rarefying osteitis 
is usually more general with loss of the linea dura and more 
tapering or irregular bone between the teeth. 




Fig. 26. — Due to abnormal occlusion. 

The complete destruction of periodontal attachment 
(Fig. 27) would indicate prompt extraction or the destruc- 
tion of alveolus beyond the level of the bifurcation of muti- 
lated teeth (Fig. 28) would furnish the conviction that treat- 
ment in such circumstances can be but palliative. When 




Fig. 27. — Complete destruction of bone. 



systemic derangements of various kinds are attributable to 
toxins from oral sepsis, the radiographic appearance of the 
alveolar bone is somewhat a guide. The presence of pus with 



PYORRHCEA ALVEOLARIS 



79 



marked rarefying osteitis, loss of the linea dura, decided 
enlargement of sockets and existence of deep pockets lend 
credence to this suspicion, but are not essential, for severe 
constitutional disturbances are sometimes caused when 



r 3 



Fig. 28.— Exposed bifurcation. 



slight periodontal disease only is present, and the radio- 
graphic appearance of the bone reveals but slight changes. 
Radiographic evidence is sometimes unreliable in diagnosing 
severity of cases, and does not coincide with the clinical 



PIP 



Fig. 29. — Extensive rarefying osteitis. 

aspect; if deep pockets exist on either labial or palatal sur- 
faces, not extending to the interspaces, these do not show on 
the picture, the shadow of the roots obscuring what may be 
a very serious condition. 



80 



TREATMENT OF PERIODONTAL DISEASE 



A general description of treatment of pyorrhoea, as a whole, 
does not embrace salient points in a comprehensive form to 
the student desirous of information on the complex problems 
which confront him in practice. Every case which presents 
itself should be first carefully examined and the local etio- 
logical factors present ascertained before commencing treat- 
ment, with a view to removing the cause and applying the 
means of restoring diseased tissues to normal. 




Fig. 30. — Affected lower incisors. 



I. The class of cases (the simplest) where the lower incisors 
are loose with pus exuding on pressure and a state of perio- 
dontal disease extending from this area backward in a less 
degree with no visible pus elsewhere. The cause is generally 
salivary calculus on the surfaces of the teeth, and sub- 
gingival calculus the product of inflammation. If on occlu- 
sion these teeth move beyond their normal limits of motion 
(which can be ascertained by placing the finger lightly on the 
teeth and instructing the patient to close sharply) the occlusal 
surfaces should be ground until complete relief from this 
traumatic factor is obtained. The removal of all foreign 
matter from the teeth surfaces with instruments and perfect 
root surgery, which consists not only in removing every 
particle of subgingival calculus but a slight planing of the 



PYORRHEA ALVEOLARIS 81 

denuded surface of cementum which has been pus-soaked 
for a lengthy period, leaves it absolutely smooth. Instru- 
mentation should be carried out farther back to every tooth 
on which the slightest nodule of calculus adheres, with a view 
to arresting the disease. Next polishing the surfaces of the 
teeth with powdered pumice made into a paste with aromatic 
sulphuric acid and water carried on engine brushes of wheel 
or cone shapes; the interspaces require most careful atten- 
tion also, which can best be done by passing fine lava polish- 
ing strips between, stretching them taut and firmly rubbing 
the gritty material against these surfaces. These strips of 
narrow width work effectively on the surfaces of all teeth 
under the gums by encircling a tooth and bringing both ends 
on the outside, then, with a reciprocal pulling motion the 
tape works itself under the gum margin and polishes those 
surfaces most effectively. During the whole course of treat- 
ment at every sitting the teeth should be polished to the 
highest state of perfection. 

The root surgery and polishing process having been thor- 
oughly carried out, the loosened teeth should be ligatured 
with fine gilt wire (Angle's fine), beginning at the nearest 
firm tooth (usually the cuspid), the wire should be inter- 
laced and, stretched taut just above the bulging contour of 
the teeth to prevent slipping down on the gums and ending 
the wire on the opposite side on a firm tooth (Fig. 31). The 
twisted ending should be tucked away to prevent any irrita- 
tion of the soft tissues. This ligaturing should leave the 
loosened teeth perfectly rigid, immovable in the enlarged 
sockets, in which position they should be held to promote 
physiological rest until regeneration of bone takes the place 
of the mechanical device. 

The possibility of regeneration of bone once affected by 



82 



TREATMENT OF PERIODONTAL DISEASE 



rarefying osteitis has been freely denied by some authori- 
ties, but clinical and ic-ray evidence is convincing that this 
actually occurs. Dr. T. Sydney Smith 1 , of California 




Fig. 32. — a, radiograph taken April 27, 1914, showing destruction of the 
alveolar process; b, radiograph of the same taken August 15, 1914; c, the 
same taken December 7, 1914, showing regeneration of bone. 

pointed this out at the Sixth International Dental Congress, 
and subsequently furnished me with the accompanying 
example, Fig. 32. It is necessary in order for this to take 

1 Transactions of Sixth International Dental Congress, p. 213. 



PYORRHEA ALVEOLARIS 83 

place that the teeth be kept steady in a condition of phy- 
siological rest. 

Root surgery alone is insufficient; the tissues and alveolar 
bone have been so weakened by chronic inflammation and the 
presence of pus that pathogenic microorganisms inhibit them 
and are able to flourish. Irrigating or syringing the pockets 
is ineffective, because antiseptic lotions are not long enough 
in contact with tissues into which organisms have penetrated 
to have any effect on them, and regeneration of tissue can- 
not take place in the presence of opposing pathogenic 
organisms. 

The author has therefore instituted ionic medication to 
cope with this etiological factor. At each sitting after the 
first surgical operation, which is usually attended with copious 
bleeding, the gingival trough should be ionized with zinc 
ions; a zinc electrode wound at the point with a little cotton- 
wool saturated with 3 per cent, zinc chloride or sulphate 
should be passed into the gingival trough to the bottom of 
the pockets, the patient holding the indifferent electrode. 
Current should be gradually turned on from the generator, 
until it is felt. Ionization should be carried out with the 
object of obtaining deep penetration with a sufficient dose of 
ions to affect the deep-seated organisms. In this respect 
the dose must be judged in direct ratio of current strength to 
time employed, that is, if the patient will only tolerate two 
milliamperes the electrode should be held in position for 
half a minute to ionize a pocket between two incisors, and 
should be gradually moved around the neck of the tooth into 
another pocket between adjacent teeth, but if 3 or 4 m.a. are 
available the time required for proper penetration of ions will 
be proportionately reduced to one-third or one-quarter of a 
minute. 



84 TREATMENT OF PERIODONTAL DISEASE 

Care should be taken that the entire gingival trough is 
subjected to the direct contact of the electrode, which is 
done in its slow movement about the neck of the tooth, 
the pocket being flooded with the zinc solution, ionization 
continues at some distance from the actual contact of the 
electrode, although penetration is deeper where contact is 
made. 

The operation should be repeated every second day until 
pus has disappeared and inflammation has subsided, when 
the interval can be extended to three days, and later to once 
a week, when ionization with iodin, using the negative pole, 
should be substituted for the zinc. A good deal of judgment 
is required in ascertaining when the tissues have had suffi- 
cient treatment. Restoration to healthy appearance is not 
in itself a sufficient guide. Existing conditions, such as a 
delicate osseous frame with fragile alveolar bone, or the 
reverse, the former imposing longer care and attention than 
the latter, also the general health, must be considered; when 
general constitutional disturbances exist the tissues repair 
more slowly than when local affections only exist. The cur- 
rent strength available also affects the dose of ions. If only 
1 m.a. has been used the restoring effect will be much slower 
than if 3 or 4 m.a. have been possible. One condition, how- 
ever, always imposes itself in all cases, and that is it must 
be the object in view to so far restore the gingivus to normal 
that in the act of eating foodstuffs will not readily pass into 
the gingival trough. The gums should be tough or con- 
tracted about the necks of the teeth before the patient can 
reasonably be expected to effectively continue daily treat- 
ment on hygienic lines. 

Nor does the operator's responsibility rest here, even in the 
most perfect looking result. Few people presenting a state 



PY0R1UKEA ALVEOLARIS 



85 



of advanced pyorrhoea possess any real knowledge of how to 
keep their teeth. Their methods have failed, and it is the 
duty of the operator to discover the lines on which they have 
worked, to correct their faults and train them in proper 
methods. Tooth-brushes, as a rule, are useless things. One 
may examine hundreds on sale and find only a small per- 
centage suitable for the purpose intended. A stiff brush 
shaped somewhat like Fig. 33, answers the purpose well, and 
it should be explained to patients that not only should the 
teeth be brushed, but gum massage with the brush is essential 



UWP *^*w 



Fig. 33 



to tone up and keep gum margins in a condition capable of 
resisting reinfection. A good dentifrice should be used to 
keep the teeth polished, followed by a few drops of some anti- 
septic wash on the brush, such as : 

R— Thymol grs. iij 

Benzoic acid 3ss 

01. cinnamon "HI x 

Acid carbolic Ill xxx 

Otto rosse 1Uxv 

Alcohol ad. giv— M. 

Interspaces should be cleaned at least once a day with 
waxed floss silk. In cases in which loosened teeth are liga- 
tured or permanent splints support them, individual cleaning 



8G TREATMENT OF PERIODONTAL DISEASE 

of spaces must be done. A bit of orangewood thinly pointed, 
moistened with antiseptic and dipped into powder, should 
be used to polish these surfaces, which neither brush nor 
silk can get at, care being taken to rinse away all powder 
after using it. 

Details of postoperative treatment of pyorrhoea cannot be 
too carefully instilled in the patient's mind, and constitute 
after-management of cases, on which depends the success 
or failure in the treatment of pyorrhoea. After a course of 
treatment the case should be dismissed for periods varying, 
according to its severity and the ability of the patient to 
carry out instructions, from six weeks to three months, when 
a thorough examination should be instituted to determine if 
instructions have been carried out and if faulty operating 
has left the smallest particle of irritant in the gingival trough, 
causing reinfection and a state of slight inflammation at 
that point. According to the ability of the patient to manage 
his own case, the future intervals when the case should be 
seen must be determined, usually three times or twice a. year. 
No cure of pyorrhoea can be ascertained in less than a year 
after treatment, but two or three years are better, some cases 
requiring constant care for even longer periods, but with 
cooperation of the patient and a determination to overcome 
every etiological factor it is remarkable the proportion of 
cases which respond to treatment, the teeth remaining 
functional and free from sepsis. 

II. The class of cases in which the superior incisors are 
principally attacked on the palatal surfaces, pus pockets ex- 
tending some distance on those surfaces, and to the approxi- 
mating spaces until the labial surfaces (which are probably 
well brushed) are reached and to all appearances are healthy. 
The teeth are often abnormally spaced, due to slight protru- 



PYORRHCEA ALVEOLAR! S 



S7 



sion. The cause is generally neglect to cleanse those surfaces, 
and here subgingival calculus alone is found. 

Etiological factors here are usually neglect or impinging of 
the lower incisors from faulty occlusion or faulty occlusion 
and stress brought to bear by the loss of molars, or even pre 
molars (Fig. 34), by which undue strain is placed on the 
incisors, establishing rarefying osteitis and chronic inflamma- 
tion of the periodontal membrane. Occasionally the lateral 




34. — Extraction of first premolar the cause of rarefying osteitis about 
the lateral incisor by faulty articulation with inferior cuspid. 



incisors alone are affected by faulty occlusion, the lower 
cuspids striking and pressing them outward at every closure 
of the jaw. 

Treatment consists in thorough instrumentation and polish- 
ing, the relieving of abnormal stress by grinding the opposing 
lower teeth, replacing into normal position teeth which 
have been forced out and thorough ionization of the gingival 
trough. Instrumentation should include the labial surfaces 



88 TREATMENT OF PERIODONTAL DISEASE 

even if apparently healthy, here a granular layer of sub- 
gingival calculus invariably exists. Replacing of abnormally 
placed teeth may involve considerable mechanical ingenuity, 
not only in regaining normal positions, but, what is more 
important, in retaining them there. Fig. 35 shows an 
extreme case of protrusion, caused by occlusion of the lower 
incisors on the roots of the uppers, and also the loss of 
various teeth in the maxilla and mandible. In this case 




Fig. 3.5. — A pronounced case of protrusion and pyorrhoea in an adult. 

Angle's retraction head-gear was employed to obtain the 
position shown in Fig. 36; grinding of the surfaces of the 
lower incisor was also necessary; lost teeth were replaced by 
artificial substitutes on plates, thus relieving pressure on the 
anterior teeth. An upper retaining plate was also made to 
be worn at night, with a wire arch attached, which fitted 
closely to the surfaces of the superior incisors, preventing the 
possibility of moving out of position. In less affected cases, 
where teeth have moved slightly and pockets are not deep, 



PYORRHEA ALVEOLARIS 



89 



ligaturing for a time after relieving pressure is all that is 
necessary until new bone is formed about the enlarged socket. 
The attachment of permanent splints is indicated in cases 
where malocclusion is not accountable for incisors becoming 
malplaced, but when long-standing pyorrhoea has brought 
about rarefying osteitis and loss of periodontal attachment 
principally in the palatal aspect, such teeth require permanent 
support after replacement. The obliteration of the pockets 




ition after treatment. 



by retraction of the teeth is in itself a means of checking the 
disease if instrumentation has been successful; but the ten- 
dency is to move outward again. Splints can be attached to 
live teeth without destruction of the pulps, and if one or two 
pulpless teeth exist they should be utilized to obtain more 
durable attachment. In the case of four vital incisors, fine 
drill holes in parallel midway between the pulp and surface 
margin of each tooth, slightly larger than the platinum pin 
of a plate tooth, 5 mm. deep, constitute the plan on which 



90 



TREATMENT OF PERIODONTAL DISEASE 



to construct a splint, which can either be cast or constructed 
by soldering iridioplatinum wire attachments on platinum 
foil burnished on the impression containing the pins in situ. 




Fig. 37. — Splint which retained these teeth for sixteen years. 

The ends of a splint for this purpose should extend to and 
rest on adjoining firm teeth on either side, not necessarily 
to be attached to them. Fig. 37 is a radiograph taken just 
before removing the teeth which were retained for sixteen 




plint on incisors. 



years by the splint. In the case of two devitalized laterals, 
which have moved outward the splint can be constructed on 
them with long pins in the pulp chambers, the bar resting 



PYORRHEA ALVEOLAR! S 



91 



on firm centrals. Fig. 38 shows a splint on incisors which 
retained these teeth for a number of years. When separation 
of central incisors alone occurs from disease between them, 
instrumentation, ionization and replacing and splinting 
them (Fig. 39), is very effective in curing and arresting 
further spread of periodontal disease to adjoining teeth. 
Splints on the superior incisors give little trouble to keep 
clean, and the fear of caries, as a result, can be ignored even 
in only ordinarily careful patients ; individual cleansing of the 
spaces with wood points by the patient and semi- yearly (at 
least) polishing by operator is sufficient. 




III. The class of cases in which the disease starts in the 
molar region, affecting the premolars less, and the incisors 
possibly very slightly, or not at all. Pockets are usually 
established between the teeth and posterior to the last 
molars, where a flap of gum retains septic matter. The 
palatal roots of the first and second molars are often denuded 
of bone and tissue covering. Septic infection is generally 
worse between the teeth, where neglect of hygiene has prob- 
ably been the principal cause of disease. Subgingival calculus 



92 TREATMENT OF PERIODONTAL DISEASE 

of a hard, tenacious character usually encircles the roots of 
the teeth impinging on the remaining periodontal attach- 
ment. Instrumentation in this position is very difficult and 
imposes on the operator a high degree of skill, patience and 
exactness (upon which hangs success) and failure often 
stares one in the face, in spite of most diligent and honest 
efforts to overcome this obstacle. This irritant cause (sub- 
gingival calculus) must be completely removed, a tedious 
operation for patient and operator alike, which may entail 
repeated searchings under the gums for small particles, and 
also the slight planing of the root surfaces. Ionization with 
zinc ions should be carried out, using the strongest current 
strength available with comfort for the patient; 5 m.a. is 
nearly always possible, and some patients can stand 10 or 
even 15 m.a. current. 

The period of treatment should extent at intervals of every 
second day, until not only pus has disappeared and the tissues 
appear healthy, but the gum tissue has shrunk close to the 
roots of the teeth, and a solid tough floor of tissue formed 
between the teeth, which can resist ingress of food particles 
to the gingival trough. 

The polishing of interspaces should be effected with lava 
strips, and all enamel surfaces polished to the highest degree 
of smoothness with port polishers, brushes or buff wheels 
and a gritty acidulated paste. The articulation of the teeth 
requires most careful study to ascertain if traumatic occlu- 
sion exists; abnormal limits of motion on closure should be 
detected; often there is no difficulty in discerning this; a 
single molar or pair of molars may be quite loose, and reveal 
considerable movement on occlusion. The radiograph also 
will show considerable rarefying osteitis with loss of linea 
dura. To correct traumatic occlusion, judicious grinding 



PYORBHCEA AL VEOLA MS 



<>: 



of the planes of occlusion should be done with carborundum 
stones, after marking the contact points with thin carbon 
paper, repeating the process of biting on the paper and 
grinding until undue stress is relieved and proper balance 
established in the denture. 

An illustration of the effects of traumatic occlusion on a 
denture is well shown in the accompanying radiographs 
and photographs of the denture. Fig. 40 shows abnormal 




Fig. 40. — Abnormal occlusion due to extraction of premolar 



occlusion in a patient, aged forty years, due to the pernicious 
operation of extracting a pair of premolars to correct irregu- 
larities in childhood. This produced impinging of the inferior 
cuspids on the superior laterals and abnormal articulation 
in the molar region, with the result that rarefying osteitis was 
specially marked on the palatal surface over the laterals and 
second molars (Fig. 41) and abnormal movement of these 
teeth, with a spreading attack of periodontal disease over the 



94 



TREATMENT OF PERIODONTAL DISEASE 



entire maxillary denture. Fig. 42 shows radiographs of the 
condition of the bone. Treatment consisted in relieving 



_ 


' 


m 




«>. 


1 









Fig. 41. — Rarefying osteitis in region of laterals and molars. 

undue pressure by grinding the lower cuspids and ligaturing 
the superior laterals for three months and relieving strain 




Fig. 42. — Radiographs of the maxillary denture. 



on the second molars. Subgingival calculus of a hard • black 
kind was removed and the gingival trough ionized with zinc 



PYORRHEA ALVEOLARIS 95 

and iodine ions. The case treated in March, 1913, has been 
seen once a year since and is now in perfect condition; the 
loosened teeth are as firm as the other teeth, and the disease 
in general arrested. The patient volunteered the statement 
that her mother, now edentulous from pyorrhoea, was treated 
by extractions like herself, and first showed the same symp- 
toms at precisely her age (forty), which convinced her that 
something was going wrong with her teeth. 

Postoperative management is of vital importance. The 
patient's habits in relation to daily hygiene should be inquired 
into and faults corrected. Dietetic errors, due to modern 
methods of food preparation, cannot be changed in a day, 
but advice can be given to counteract some of its effects. 
The adhesion of soft, sticky food to the approximating 
surfaces of teeth in the molar region is one of the mosc 
difficult aspects of recurring infection in this part, but this 
can be often overcome by advising (in addition to hygienic 
methods already referred to) the use by patients of fresh fruit 
after the last meal of the day. This is an effective means 
also of preventing the formation of salivary calculus in other 
parts of the denture. Environmental forces should also be 
considered and inquired into. The effect of closed windows, 
unhealthy atmospheres, sedentary life, lack of exercise — 
everything in the habits of the patient opposed to natural 
and primitive environment comes under the category of 
investigations the dentist should institute for the betterment 
of chronic disease of the alveolus. 

IV. The class of cases differing from the foregoing (so 
frequently seen in this country), caused by the ruthless 
extraction of molars, sometimes maxillary unilateral, some- 
times bilateral, the mandibular molars being retained, or 
vice versa, the mandibular, the maxillary retained. The 



96 TREATMENT OF PERIODONTAL DISEASE 

undue stress of mastication thus brought to bear on the 
anterior teeth is the undoubted cause of periodontal disease 
developing in the denture, which therapeutic and surgical 
treatment alone cannot overcome. Dentures are often 
supplied, which are a source of irritation, or inadequate in 
restoring balance. Treatment in such instances consists in 
the already described surgical and ionization methods, and 
in addition careful restoration of balance of the denture by 
replacing lost teeth by methods which ensure the most 
perfect articulation in the molar region without producing 
irritating pressure on the gingivus in the vicinity of diseased 
teeth. Plates should be constructed with well-fitting saddles 
to resist the strain of mastication, and if clasps are necessary 
they should fit clear of the gingival border without a dragging 
influence on the teeth clasped. In the mandible it is often 
possible to construct plates carrying lost molars, on the 
principle advocated by Mr. Badcock, by a solid wire bar 
fitted to the curve of the jaw below the gum margin, attached 
to well-fitting saddles and clasps on the premolars. 

The most perfect method of restoring balance of articula- 
tion, and relieving undue stress by loss of molars or premolar 
teeth, when circumstances permit, is by fixed or removable 
bridges. These should be constructed so as not to violate 
the principles of antiseptic surgery — a difficult matter, which, 
by many, will be stigmatized at once as impossible, but which 
nevertheless can be carried out by those expert in this method 
of restoration. One of the most antiseptic methods of 
bridging in these cases consists in the "suspension" bridge 
(Fig. 43), which can often be constructed on inlay abutments. 
This leaves a clear space of considerable width between the 
restored surface and the gums, and patients should be 
instructed in the method of cleansing by occasionally passing 



PYORRHEA ALVEOLARIS 



97 



a strip of tape underneath and polishing the surface which 
cannot be cleansed by the brush. 

V. The class of cases which owe their origin to badly con- 
structed fillings or crown and bridge-work is exceedingly 
common, and is confined to mouths prone to caries, and con- 
sequently not so predisposed to virulent periodontal disease. 
The disease is generally confined to local areas, influenced 
by this exciting cause, but may have spread generally by 
contagion before discovered. Treatment consists in remov- 
ing the cause and carrying out the principles of surgical and 




Fig. 43. — Suspension bridge in position. 



therapeutic treatment by ionization. Pockets established 
between the teeth which have been filled leaving imperfect 
edges or with imperfect contour, usually assume a wedge 
shape (Fig. 44), the lodgment of food by pressure forcing the 
gum against the absorbing alveolar bone. The regeneration 
of bone and gum in this circumstance does not occur and an 
awkward space exists, which requires special attention by 
the patient. Fillings which are the cause of such a condition 
should be removed and the disease treated by ionization 
until the tissues have resumed the normal and a tough, well- 
contracted gingival floor is established, when they should 
7 



98 TREATMENT OF PERIODONTAL DISEASE 

be replaced with fillings having anatomically correct contact 
points and perfect cervical edges. Flat, shapeless fillings 
simply aggravate the trouble by providing spaces which 
permit of the lodgment of food. When these spaces occur 
fairly near the front of the mouth, in addition to cleansing 
with silk, some patients have used an adaptable steel instru- 
ment which, on several occasions, the writer has entrusted to 
them with results which were most gratifying. 




Fig. 44. — Wedge shaped pocket. 

As regards crown and bridge-work, there is no doubt that 
a vast amount of oral sepsis is created and maintained by 
faulty construction or unwise selection of cases for this much 
abused method of restoration. But of the two evils — a 
questionable amount of sepsis from a well-constructed crown 
or bridge, or the loss of balance in the denture from the lack 
of teeth — the former will appeal to the minds of all who 
understand the hopelessness of undertaking to cure even 
slight periodontal disease, not to mention established pyor- 
rhoea. Crowns and bridges are often so constructed that 
they can only be classed in the category of "septic surgery," 
so justly condemned by Hunter; these should be removed, 
and when attached to roots hoplessly affected by pyorrhoea, 
the roots should also be removed: the restoration of the 



PYORRHEA ALVEOLARIS 



99 



denture to health should take the lines of treatment already 
described under instrumentation, polishing, ionization and 
proper hygienic methods. 

The question of replacing crowns or bridges after the 
tissues have been restored must be governed by circumstances. 
Gold shell or banded crowns on teeth which have been 
affected by pyorrhoea from no other cause than an ill-fitting 
band in contact with the gingivus, if replaced by even most 
perfect work might be the cause of recurrence; but porcelain 
crowns and bandless crowns of all descriptions, which have 




with a perfect joint. 



no joints to catch and retain foreign matter (Fig. 45), have 
no more influence on periodontal disease than natural teeth 
affected similarly, and can be retained in quite as healthy a 
condition. 

VI. The class of cases which some writers would attribute 
to "predisposing causes" furnish the most difficult to deal 
with. They are often associated with a frail osseous frame, 
thin, narrow jaws, a delicate constitution or the accompani- 
ment of some systemic derangement, which, in the majority 
of cases, is caused by oral sepsis. 

The treatment of periodontal disease for patients in this 



100 TREATMENT OF PERIODONTAL DISEASE 

category imposes on the dentist a grave responsibility. 
Cases are usually referred to him by the medical practitioner, 
who is quite incompetent, as a rule, to discern for himself 
if oral sepsis in reality exists, and is likely to be the cause of 
infection accountable for such ill effects as enumerated by 
Hunter, viz., "the general ill health, dirty, sallow complexion, 
the indigestions, the gastric and intestinal troubles, the 
anemias which resist treatment, the tonsillitic, pharyngeal 
and glandular troubles of children, the chronic rheumatisms, 
obscure fevers and blood poisonings, etc." Here judgment 
must be exercised in determining, apart from the existence 
of septic infection of the mouth, the degree of infection and 
the possibility of retaining the infected teeth. Under the 
cloak of "predisposing causes" a section of the profession 
endeavor to hide their own inability to overcome the increased 
difficulties caused by relationship to other existing diseases, 
they ignore the possibility of local infection being the sole cause 
of constitutional disorders, and that with the disappearance 
of local septic infection the constitutional derangement due 
to toxins will disappear, and the dreaded intractable disease 
resolve into an ordinary local infection amenable to local 
treatment, and the regeneration of alveolar bone and tissues 
take the ordinary course, aided by improved general condi- 
tions. 

Under the heading of "Cases not Favorable for Treat- 
ment," Colyer 1 includes "those showing well-marked signs 
of rarefying osteitis and with general and local conditions, 
which indicate that the tissues have little recuperative 
power." In other words (as is carefully explained in the 
chapter under this heading), every tooth with a pyorrhoea 

1 Chronic General Periodontitis, p. 88. 



PYORRHCEA ALVEOLAR IS 



101 



pocket actively discharging pus should be extracted " at the 
earliest opportunity." Any other line of treatment, in his 
opinion, is unsatisfactory, and he urges that "early removal 
of the teeth in cases in which the disease is making progress 
is also of practical importance." This doctrine of free 
extraction, that is extraction of all the teeth, coming from 
such a well-known authority, who has done useful work on 




morbid anatomy and pathology of periodontal disease, one 
might hesitate to condemn had not Colyer, in his argument 
for this course, condemned it himself by publishing skia- 
grams 1 (Fig. 46), reproduced here, of a typical case which 
shows conclusively that proper local treatment (which 

1 Chronic General Periodontitis, p. 90. 



102 TREATMENT OF PERIODONTAL DISEASE 

extended over eighteen months) had not been carried out. 
Examine the radiograph — more beautiful examples of sub- 
gingival calculus which existed in the first picture and had 
increased in the second, could hardly be found! The calculus 
had not been removed; the irritant cause of pyorrhoea had 
been left behind during all this time. The kind of local 
treatment employed is not chronicled, but whatever it was 
it did not include removal of subgingival calculus, and on 
the strength of the results, which were bad, the patient was 
made edentulous. Vaccines, which were used, could have no 
effect while the local cause remained. That should not be 
the lines on which the dental profession should work. Some 
serious effort should be made to retain the denture in these 
cases, for it will be found that often the disease can be 
checked and the septic source eliminated, it may be only 
temporarily at first, but carefully following up the treatment 
and watching over the case to prevent recurrence of the 
slightest inflammation of the gingivus, eliminates sepsis of 
the oral tissues, which, if it is the source of toxins, will have 
the desired effect on the associated pathological condition 
elsewhere and in time be reflected on the local condition. 
The writer has in this way saved many a denture, where the 
constitutional disorders have been shown to react, as in one 
case of anemia particularly, which took three years to com- 
pletely disappear, but eventually it did, and the local affection 
also, leaving the patient with a functional denture, which in 
appearance and utility far surpasses the most skilfully con- 
structed artificial substitute. 

Advanced cases of pyorrhoea, when no active pathological 
lesion is suspected, but a frail osseous frame or delicate 
constitution indicates the likelihood of ready absorption of 
organisms into the medulla of bone or the weakening of the 



PYORRHEA ALVEOLARIS 103 

gastric defences, provides a difficult class of subjects to deal 
with. Nevertheless, if rarefying osteitis has not advanced 
generally so as to loosen all the teeth, but only in certain 
areas, it is of great advantage to these people to retain all 
teeth possible to provide organs of mastication and support 
for artificial substitutes. Thorough instrumentation and 
electro-sterilization will usually clear up the disease, but a 
great tendency at first to recurrence is generally observed. 
This tendency should be mentioned to the patient and in- 
structions given to return three months after treatment for a 
clean-up and ionic medication of the gingival trough. Future 
management of the case rests principally with the patient, 
who should be well instructed in an effective method of 
hygiene and gum massage with the brush. These cases 
require to be seen at regular intervals of four months for a 
year or two, after which it is often gratifying to find improved 
tone in the tissues, which resist infection and a decided 
strengthening of the alveolar investment. 

The tendency to recurrence need not be interpreted as 
failure, especially if the sockets are not enlarged and teeth 
consequently loosened; but the possibility of some irritant 
cause being left behind, or tissue not having sufficiently 
recuperated to resist microorganisms, should be etiological 
factors kept in mind, and treatment continued by additional 
instrumentation, including the planing of the root surfaces 
where pus persists and prolonged electro-sterilization. The 
presence of amcebse can invariably be detected, and the author 
has found that the use of tincture of ipecac on the wet brush, 
once daily in the morning, as well as the antiseptic wash at 
night, assists in overcoming this tendency to recurrence of 
the disease. 

It has been the writer's gratifying experience to have on 



104 



TREATMENT OF PERIODONTAL DISEASE 



record many cases of this class, which resisted treatment at 
first for two or even three years, then became absolute cures. 
In order to wait so long for results, serious pathological 
symptoms in other parts of the body must be absent. 

VII. Cases associated with active pathological lesions 
elsewhere are exceedingly common. In the author's experi- 
ence the}' include the following in order of greatest fre- 
quency: General ill health, rheumatic symptoms, gastric 
and intestinal troubles, tonsillitis, obscure temperatures, 
anemia, rheumatoid arthritis, glandular swellings, neuras- 




Fig. 47. — Space liable to reinfection. 



thenia, inflammatory diseases of the eye, etc. Treatment 
of pyorrhoea in this class of cases imposes on the dentist 
scrupulous care that not only is the source of sepsis removed, 
but that the mouth is left in such a hygienic condition 
that it is humanly possible for the patient to keep it so. 
Potential sources of infection, which cannot be reached in 
the daily hygienic efforts of the patient, should be elimi- 
nated by extraction, such as multirooted teeth with exposed 
bifurcations denuded of alveolar and gum covering (Fig. 47) ; 
deep pockets in the molar interspaces (Fig. 48) ; semi-impacted 
mandibular third molars; teeth with pyorrhoea abscesses, 



PYORRHEA ALVEOLAR! S 



105 



especially in the mandible, where gravitation of pus usually 
extends rapidly toward the apices; teeth so loosened by alveo- 




Fig. 48. — Deep pocket between molars. 




Fig. 49. — Pyorrhoea abscess. 




Fig. 50. — Granuloma. 



lar absorption and rarefying osteitis that abnormal move- 
ment takes place on closure of the jaws or in mastication; and 
all dead teeth with granulomas (Fig. 50) or chronic abscesses 



106 TREATMENT OF PERIODONTAL DISEASE 

discharging on the gums, indicated by the radiographs. 
These furnish instances when extraction of teeth becomes 
necessary, as an adjunct in the relieving of pathological 
general symptoms in treatment of the disease by conservative 
methods, details of which have already been described, con- 
sisting of instrumentation, cleaning and polishing of tooth 
surfaces, removing of irritant factors such as faulty crown 
and bridge-work, imperfect fillings, restoration of normal 
balance in the articulation and dealing with the micro- 
organisms by electro-sterilization of the gingival trough about 
all teeth retained. 

A complete cessation of the disease must be ensured, no 
pus-yielding pockets must be allowed to persist and the gums 
should contract about treated teeth, so as to resist reentry of 
soft food into the gingival trough. 

Periodontal disease which has existed long enough to affect 
the alveolar bone seriously, with deep pockets about the 
teeth and denuded sockets, from which badly diseased teeth 
have been removed, involves the bone in areas of necrosis 
of varying extent, necessitating surgical interference during 
treatment. Deep pockets passing below the alveolar level 
produce a surface of necrotic bone, which should be scraped 
or curetted to remove all dead bone. This in many cases can 
be done with a spoon-shaped instrument, or in the case of 
extraction the socket should be burred with a large round 
bur until the necrotic surface is removed. The particles of 
detached bone should be removed by syringing with an anti- 
septic lotion or by wiping out the pockets with medicated 
cotton-wool on a barbed probe. The persistence of pus at -a 
particular location is usually an indication that necrotic bone 
remains and further curetting is necessary. The use of a 
local anaesthetic is often required in the operation on necrotic 



PYORRHEA ALVEOLARIS 107 

areas; the tissues are readily anaesthetized, which facilitates 
thorough work. 

When oral sepsis is the source and supply of toxins respon- 
sible for other pathological lesions present, successful treat- 
ment invariably relieves it, and often within a very short 
time signs of improvement are manifest. With improvement 
in the general symptoms the local inflammation takes on more 
active improvement also, both depending on removal of 
sepsis. It has become very general for medical and dental 
practitioners to advise extraction of every tooth in the mouth 
in cases in which marked constitutional symptoms are 
attributable to oral sepsis. This drastic procedure invariably 
involves numbers of useful sound teeth, which can readily 
be retained without the least risk to the patient if proper 
dental treatment is carried out, and the writer has no hesi- 
tancy in condemning it in most emphatic terms. The follow- 
ing is an example of how unnecessary this method often is. 

Miss R., aged twenty-nine years, consulted me in January, 
1898, advised by her doctor and dentist to have all her teeth 
extracted. Pyorrhoea pockets existed on the palatal aspect 
of the superior incisors, extending nearly to the apices, with 
considerable discharge of pus and teeth much loosened. The 
lower teeth were all slightly affected. The patient was 
nervous and debilitated, the effects of alimentary toxemia. 

Treatment consisted in extracting one tooth (a premolar) 
and reducing every etiological factor responsible by methods 
of instrumentation, retraction of superior incisors (see Fig. 
51), electro-sterilization and restoration of balance in the 
denture by artificial substitutes. In eight weeks the pyorrhoea 
had completely disappeared and the general health improved 
to a remarkable extent. For twenty years the patient has 
retained her teeth in a functional and healthv condition and 



108 



TREATMENT OF PERIODONTAL DISEASE 



enjoyed good health, in the meantime requiring no more than 
the ordinary attention, which all patients should have. 




Fig. 51. — The upper model taken about ten years after treatment shows 
growth of alveolar over incisors. 



General Considerations. — Instrumentation and the polish- 
ing process almost invariably produce sensitive surfaces of 
teeth, which react more or less violently to thermal changes 
and the action of acids and sweets. This discomfort is often 
bitterly complained of by patients, and is, indeed, an awk- 
ward result, which if it persisted would condemn the method 
of treatment; but fortunately the obtunding effect of zinc 
ions is never-failing, and although at first this very symptom 
retards the use of heavy currents for ionization, still the 
sensitiveness is usually quickly overcome, and by the end 
of a course of treatment it generally disappears, or else is so 
reduced as to be readily tolerated, and eventually it dis- 
appears. Occasionally it persists, and when it occurs in 
positions such as the roots of molars or palatal and lingual 
surfaces of other teeth, where black discoloration of the 



GENERAL CONSIDERATIONS 109 

teeth does not matter, it can be immediately relieved by 
drying the sensitive surface and painting it with saturated 
solution of nitrate of silver. This, if allowed to stay on for a 
few minutes, will obtund the sensitive dentinal nerve endings 
and relieve the condition after one or two such applications. 
In front teeth ionization of the tooth surface with zinc ions 
will eventually produce the obtunding effect. 

In many cases of pyorrhoea the teeth are coated with trans- 
parent or translucent sticky mucus, which is septic. This 
should be carefully removed by brushing at each treatment 
with an alcoholic wash or acidulated powder, leaving abso- 
lutely polished surfaces. The interspaces should be cleaned 
with fine strips. Occasionally this mucus secretion is 
found in large quantities, the mucous glands being infected 
secrete an abnormal fluid resembling pus. Patients will 
complain that in the morning the teeth are covered with 
"pus," when there is no apparent discharge from the gums. 
This condition can be relieved by ionizing the mucous sur- 
faces with 10 per cent, iodine solution, using a flat platinum 
electrode covered with cotton-wool saturated with the solu- 
tion. The gums and mucous membrane above the level of 
the roots of the teeth should be treated. Usually 10 m.a. 
current can be used, and the iodine, as it is ionized, passes 
into the tissues, leaving a bleached appearance to the medi- 
cated wool. By slowly moving the electrode over the gums 
every part should be medicated. 

Foetid odor, which is characteristic of the disease, rarely 
persists after the disease is under control, but this disagree- 
able feature occasionally remains, when no apparent cause 
from periodontal disease warrants it, and examination of 
the tonsils or antrum is then advisable. The author has 
often discovered an infected state of the antrum or tonsils, 



110 TREATMENT OF PERIODONTAL DISEASE 

which may have resulted from oral sepsis, and until this has 
been attended to by a throat and nose specialist the condi- 
tion of the mouth remains intractable, with inclination to 
reinfection, and treatment of pyorrhoea is not effective. 
The vigorous maintenance of treatment, which at first 
should be every second day, and polishing the teeth each 
time, is intended to keep away the formation of bacterial 
plaques on the teeth, and reduce to a minimum the influence 
of organisms in an infected mouth, while ionization of the 
gingival trough deals effectively with organisms in the tissues 
themselves. At the same time it is necessary to determine 
if any irritant specks of calculus are left, even after the most 
perfect instrumentation, and as treatment advances there 
is no surer sign that tartar has escaped the instruments, 
than to find here and there a slightly inflamed interdental 
papilla or a margin of gingivus. There is not the slightest 
detriment to the periodontal membrane from reentering the 
gingival trough to perform the necessary removal of tenacious 
calculus, even if this reentry has to be undertaken at every 
sitting throughout a long course of treatment; when the 
tissues are perfectly healthy no bleeding will occur from the 
use of instruments on the roots of teeth which once would 
bleed on the slightest touch. 

Instrumentation. — The technic of instrumentation must 
rest with each individual operator and description of instru- 
ments would be futile; suffice it to say that vast numbers of 
instruments are exhibited by instrument makers, which are 
to the writer's mind totally unsuited to carry out what 
should be the intention of the operation ; the object being to 
remove all necrotic tissue adherent to the roots and cal- 
careous deposits. Instruments should have keen cutting 
edges, with rigid shafts of finest steel, and of a size that 



INSTRUMENTATION 111 

will not lacerate unnecessarily overlying soft tissues. Just 
above the deposited subgingival calculus is always an area 
of vacant space before reaching fibers of periodontal tissue 
(Fig. 52) ; into this space if a blunt-ended hook-shaped instru- 
ment is passed, a firm, steady pull in the direction of the shaft 
planes off adherent foreign matter and removes it. The 
important part is to accomplish this object by the methods 
best known to the individual. It should be unnecessary to 
refer to this purely surgical detail, but the writer's experi- 



-A, salivary calculus; B, space above calculus; C, peridental 
membrane; D, inflamed gum tissue. 



ence is that there is no operation in dentistry so little under- 
stood, or so imperfectly performed generally, as the removal 
of subgingival calculus. 

Much can be done toward relieving periodontal disease 
by skilful instrumentation and after-management of cases 
alone, but in the author's opinion these are insufficient, as 
they leave too much to nature in the matter of overcoming 
infection of the gums, periodontal tissue and alveolar bone, 
into which pathogenic organisms penetrate and are not 
reached by any form of antiseptic spray or irrigation. 



112 TREATMENT OF PERIODONTAL DISEASE 

Other Methods. — There are doubtless many other methods 
instituted by successful practitioners for dealing with 
advanced periodontal disease, and claims of curing it are 
freely made, and doubtless with skilful instrumentation, 
aided by osmotic methods of applying certain drugs, and 
with due consideration to every etiological factor, these 
results are attained, but the writer emphasizes the quicker 
and more universal results obtained by medicating the tis- 
sues with antiseptic ions, which deals with deep-seated 
organisms at the outset, and relieves the strain imposed on 
recovering tissues by providing antibodies to combat patho- 
genic organisms. 

Vaccine Therapy. — The method of treatment by vaccines, 
which is based on one of the most important scientific dis- 
coveries in medicine, is irrational and impractical in the case 
of this localized disease, which is admitted to be dependent 
on the action of no particular organism, but purely 
secondary in infection by any of a complex group of 
organisms ever present in the oral flora. The selection of 
one or two varieties of organisms from which to prepare an 
autogenous bacterial vaccine, in the present state of our 
knowledge, is hazardous, and even if precise knowledge 
can be obtained by staining organisms in specimens of 
diseased tissues removed from the patient, vaccine 
therapy is quite unnecessary in the treatment of this local 
infection, which can be treated successfully from a local 
standpoint. In grave constitutional disturbances due to 
absorption of toxins from a pyorrhceal source, undoubtedly 
vaccines composed of correct organisms responsible possess 
distinct value in establishing immunity, but no cure of either 
the local or constitutional derangement can be effected 
without skilful local treatment including strict observation of 



VACCINE THERAPY 113 

every other local etiological factor. The author has noted 
many cases of serious pathological lesions in other parts of 
the body due to toxins supplied from oral sepsis treated by 
autogenous vaccines and imperfect local treatment, which 
resulted in little or no improvement, but when carefully 
treated locally by instrumentation and ionization were ulti- 
mately relieved of both local and constitutional affections and 
thereafter retained singularly effective immunity, which he 
is inclined to attribute in some degree to the effect of the 
vaccines. An instance of this may be recalled in a case of 
rheumatoid arthritis referred to on p. 51 which maintained 
recovery from the local and arthritic conditions in a striking 
manner after local treatment, but did not yield to a long 
course of vaccine treatments. 

The local aspect of periodontal disease seems to be yet 
taken too lightly by the dental profession, who overlook 
or ignore the importance of incipient infection of the oral 
structures about the teeth, and do not realize that perio- 
dontal disease is preventable. As a rule the progress is slow 
and ample opportunity is presented to forestall the develop- 
ment of that stage which is termed pyorrhoea. The coopera- 
tion of the patient is more easily obtained in the early stages, 
when it does not impose such difficulties as arise later on. 
The habitual scrutiny of the gingival trough and removal 
of every particle of irritant from the teeth of all patients is 
not only of incalculable value to patients, but makes the 
operator expert in the instrumentation necessary when cases 
come under treatment suffering from advanced pathological 
changes, often due to perfunctory treatment or lack of any 
treatment, owing to pessimistic opinion prevalent on the 
prognosis of all cases of pyorrhoea. 
.8 



CHAPTER VII. 
PROGNOSIS OF PERIODONTAL DISEASES. 

A glance at recent literature on the subject is sufficient to 
convince anyone that widely divergent opinions exist on the 
important point of the cure of pyorrhoea. It is not uncommon 
to find an article on the subject prefaced with the question : 
"Can pyorrhoea be cured?" or the assertion "pyorrhoea can 
be cured," or the conclusion at the summing up of an article 
"the disease cannot be cured." 

The author has avoided the word "cure," while the prin- 
cipal endeavor has been to point out, not only that it can be 
cured, but that it should be the duty of every practitioner 
to approach the subject with that purpose in mind, on con- 
servative lines. In the incipient stages of periodontal disease, 
it is generally conceded that the disease is curable, but the 
difference of opinion begins where the strict use of the word 
"pyorrhoea" is applicable. Those who have mastered the 
surgical technic and etiological problems in their method of 
treatment doubtless have ample clinical proof of the cure of 
pyorrhoea, knowing full well that the duration of that cure 
rests with the patient, and the gratifying results are due to 
cooperation of the patient; nevertheless, that their treatment 
and advice has effected a cure cannot be doubted. The object 
of every practitioner should be to effect a cure on the most 
conservative lines without undue risks in cases of patho- 
logical lesions in the systems being aggravated by recurrence 



PROGNOSIS OF PERIODONTAL DISEASES 115 

from whatever cause — (sometimes either negligence or ina- 
bility on the part of the patient), bearing in mind that with 
elimination of oral sepsis the toxemic effect from that source 
will be relieved and the general improvement reflected at the 
local site of affection. Constitutional derangement is far too 
often attributed to oral infection, while that is only reflexly 
augmentary, and wholesale extraction of teeth advised by 
pessimists to the ultimate detriment of the condition of the 
patient who loses the vital asset of a functional set of teeth, 
often without improvement in the systemic lesion. 

From carefully kept statistics the writer chronicles the 
following cases of cures: 

I. Mrs. M., age about thirty-eight years, first seen on 
September 27, 1901. Periodontal disease general, suppura- 
tion about left lower incisor and right first premolar which 
were so loose that extraction of these two teeth was neces- 
sary: the superior left molar and premolar region also badly 
affected. 

Treatment consisted in instrumentation, polishing and 
ionization with zinc ions, the disease was arrested after six 
treatments; the case has been seen twice or three times yearly, 
when only cleaning was necessary. There has been no recur- 
rence of disease, on the contrary, in the regions of the worst 
affection the alveolar bone has developed abnormally. When 
last seen in March, 1919, the gums were perfectly normal. 
There seems to be no reason why these teeth, which are 
unusually strong, free from caries, and set in well developed 
jaws, should not continue in this healthy state as long as 
their owner lives, provided she is able to continue her method 
of daily hygiene, which includes the use of silk. This is indis- 
putably a cure of pyorrhoea, even if in future the disease 
recurs it cannot affect the claim of its having been cured. 



116 



PROGNOSIS OF PERIODONTAL DISEASES 



II. Mr. A., aged forty-two years, first seen October 11, 
1910. Sent by Doctor with warning of existing syphilis: 
two mucous patches, general health badly impaired. Radio- 
graphs indicated considerable rarefying osteitis about lower 
incisors which were loose (Fig. 53), periodontal disease 
general. Etiological factor was subgingival calculus, revealed 
by .r-rays. Local treatment consisted in instrumentation, pol- 
ishing and ionization with zinc and iodine ions; eight treat- 
ments — suppuration ceased and gingivus healthy. Patient 
seen twice a year subsequently when cleaning was done and 




Fig. 53. — Rarefying osteitis and enlarged sockets. 



occasionally ionization of lower incisors which have not only 
remained healthy, as well as other parts of the mouth, but 
when last seen in January, 1919, the patient remarked that 
the once loosened teeth were firmer than he remembered 
them to have been for many years. Without treatment it is 
probable that every tooth of this denture would have been 
lost within these nine years, instead of being healthy and 
functional as they now are. 

III. Miss R., aged about thirty years, first seen February 
14, 1911. General health impaired, neuritis in left shoulder. 
General periodontal disease which was in advanced stage of 



PROGNOSIS OF PERIODONTAL DISEASES 117 

pyorrhoea in the maxillary incisor region due to malocclusion; 
deep pockets on palatal surfaces and teeth much displaced 
outward. 

Treatment consisted in instrumentation and ionization 
with zinc ions, displaced superior incisors were retracted and 
inferior incisors ground clear of the bite; a retaining plate 
with gold wire arch was used constantly at first and always 
at night since; all suppuration ceased and the condition of 
the gingivus became normal after twelve treatments. Con- 
stitutional derangement disappeared in three months, and 
the patient was free from neuritis which had existed for two 
years. The patient, who lives in the country, has only been 
seen once a year. There has been no inflammation of the 
gingivus since and salivary calculus well kept away. When 
last seen in February, 1919, the general health was good, 
there had been no neuritis, and the teeth were firm with 
unmistakable clinical evidence of regeneration of bone about 
the incisors. 

IV. Mrs. P., aged about fifty-five years. Seen April 29, 
1910. Periodontal disease general, suppuration principally 
in the molar region on each side where well constructed 
bridges had supplied lost teeth for fifteen years. Rheumatic 
symptoms of increasing severity had appeared about a year 
previously. 

Treatment consisted in removing the bridges and extract- 
ing all diseased roots; their places supplied with plates; 
instrumentation and ionization with zinc ions, nine treat- 
ments. The disease was completely arrested and the gingivus 
made healthy. The rheumatic symptoms were very much 
less in six weeks, and continued to improve during the follow- 
ing year. The case has been seen every six months and the 
gingival margin kept healthy by cleaning and occasional 



118 PROGNOSIS OF PERIODONTAL DISEASES 

ionization when symptoms of inflammation appeared at 
any place. Constitutional derangement has completely dis- 
appeared and any tendency to recurrence of the local lesion 
readily yields to treatment which the patient is glad to apply 
for. 

These are but a few examples of what may be termed cures 
of pyorrhoea which probably any practitioner who endeavors 
to cure pyorrhoea at all can verify in his personal experi- 




Fig. 54. — Radiograph of condition. 

ence. Still there exists in this country a section of the pro- 
fession who look on such cases as hopeless and attempt no 
treatment but extraction. Many there are who either 
mislead their patients by not mentioning the fact of existing 
periodontal disease until it cannot be longer kept from them 
when extraction is advised, or fail to diagnose it in the early 
stages and are pessimistic as to prognosis when pus super- 
venes. 

The public undoubtedly is to blame for much of the pre- 



PROGNOSIS OF PERIODONTAL DISEASES 119 

vailing appalling oral sepsis now prevalent in this country 
which, but for nature's part in providing a barrier to the 
absorption of toxins, might well amount to a national 
calamity; if toxins from the mouth are accountable for as 
many ills as some medical men assert, there would be only a 
small proportion of really healthy people in the community. 



CHAPTER VIII. 
NOTES ON IONIC MEDICATION. 

Definition — Ions — Electrolytes — Dissociation of Ions — Electro-positive 
and Electro-negative — Ions and Velocities of Ions — Depth of Penetration — 
Density — Therapeutic Effect of Various Ions — General Considerations. 

Definition. — Ionic medication is that method of treatment 
in which electricity is employed to set in motion in a definite 
direction the soluble constituents of an electrolyte. The 
tissues of the body are conductors of current and ionic medi- 
cation is the introduction of drugs into the tissues by conduc- 
tion of the current, which modifies and changes the chemical 
constituents of the drugs employed and the tissues through 
which the current passes. 

Ions. — The term "ions" was employed by Faraday to 
mean a moving particle in explanation of the phenomena 
observed when electrical currents are passed through electro- 
lytes, and is employed electrically to imply the migration in 
a conducting solution of the chemical products of decom- 
position — , those which are positively charged, "kations," 
move away from the positive poles, and those negatively 
charged, "anions," move away from the negative pole. The 
direction of electrically charged ions is toward the opposite 
pole, and there is a double movement of ions going on, the 
kations toward the negative and the anions toward the posi- 
tive pole. The ions of a salt differ from the atoms of that 
salt in that they convey electric charges, and are the con- 
veyers of electric current in a solution. 



DISSOCIATION OF IONS 121 

Electrolytes. — Many chemical substances which are soluble 
in water are good conductors of electricity, and are called 
electrolytes. Pure water is a bad conductor, but the addition 
of a salt or acid increases the conductivity, so that although 
the water is a medium necessary in the composition of the 
electrolyte, it is the salt or the acid which conducts. The 
substances which in water form good conducting solutions 
undergo chemical decomposition when a current is passed 
through the solution, and the ions migrate in definite direc- 
tions to either pole. The body is an electrolyte rich in ions, 
which, when a current is passed, are the means of conduction, 
and the quantities of its ions which migrate bear a direct 
proportion to the amount of electricity which passes, and the 
electro-chemical equivalent of its constituents. 

Dissociation of Ions. — The theory of dissociation of a salt 
in a solution is explained by Arrhenius and provides an 
explanation of conduction of currents by ions in solutions. 
The solvent action of water on a salt splits up the molecules 
of the salt into ions of its chemical composition, so that a 
solution containing sodium chloride, for example, contains 
sodium chloride in part dissociated into Na ions positively 
charged and CI ions negatively charged. In a solution 
through which no current is passing the ions move in no 
definite direction, but when a current is passed the movement 
of ions takes place in a definite direction, the positively 
charged Na ions toward the negative pole, and the negatively 
charged CI ions toward the positive pole, and it is a double 
movement at the same time between the poles. The ions 
of metals, alkaloids, ammonia and hydrogen have positive 
charges, the ions of acids and hydroxyl (OH) have negative 
charges. Ocular demonstrations of the movement of ions 



122 NOTES ON IONIC MEDICATION 

have been furnished by Leduc, 1 Lewis Jones, 2 Finze 3 and the 
author 4 has experimentally shown that ferrous ions migrate 
from the positive pole about an iron electrode immersed in 
egg albumen, in which ferricyanide of potassium has been 
incorporated; when a current is passed ferrous ions migrate 
away from the iron electrode toward the negative pole and 
can be seen moving in the electrolyte, which colors the ions 
blue. Abundant proof from a clinical standpoint has been 
chronicled by medical and dental writers of the migration of 
ions into the tissues by the action of the current. 

Electro-positive and Electro-negative Ions and Velocities of 
Ions. — From the foregoing it has been pointed out that the 
action of the current on certain molecules in solution is to split 
them and repel the ions in a definite direction, the ions which 
are positively charged are repelled from the positive pole and 
carry a positive charge with them, these are electro-positive; 
those which are negatively charged are repelled from the 
negative pole, these are electro-negative. The basic radicals 
are positively charged, and the acid radicals are negatively 
charged. There are many substances which are frequently 
employed in electro-therapeutics, that are formed by the 
union of metallic radicals and acid radicals, such compounds 
as sodium chloride, zinc chloride and sulphate, copper sul- 
phate, potassium sulphate, etc., which when acted upon by 
the current separate into electro-positive and electro-negative 
ions. The direction of movement of ions contained in a solu- 
tion must be known in order to determine the proper pole with 
which to apply the medicine. For example, if zinc ions are 
required from zinc chloride and the negative pole be applied 

1 Electricity in Medicine, p. 197. 

2 Ionic Medication, Frontispiece and p. 8. 

3 British Med. Jour., November 2, 1912. 

4 Sttirridge: Dental Electrotherapeutics, 1st edition, p. 214. 



DISSOCIATION OF IONS 123 

to the site of medication, chlorine will be liberated, but no 
movement of zinc ions. The following table of electro-posi- 
tive and electro-negative substances gives the electro-chemical 
equivalents calculated to show the amount in milligrams, 
liberated by one milliampere for one minute according to 
Lewis Jones and also the relative velocities of different ions 
as measured by Leduc for the human body. 

Electro-positive (Rations). 

Milligrams per 

Milliampere 

Minute. 

Ammonium 0.003 

Cocain 0.012 

Gold 0.04 

Hydrogen 0.0006 

Magnesium 0.007 

Mercury 0.062 

Potassium 0.024 

Quinine 0.234 

Radium 0.066 

Silver 0.06 

Sodium 0.014 

Zinc 0.02 

Electro-negativ e (Anions). 

Bromine 0.049 

Chlorine 0.022 

Hydroxyl 0.01 

Iodine 0.078 

Salicylic acid 0.085 

SO-4 0.029 



"To estimate the quantity of an ion which will be intro- 
duced into the body in a given time by a given current 
requires the consideration of two factors. One of them is 
the electro-chemical equivalent, and the other is the ionic 
velocity of the ion concerned. Only the electro-chemical 
equivalent need be considered if we wish to calculate the 
amount of a substance liberated at the poles of an electro- 



Relative 


relodties, 


Leduc. 


1. 


56 


0. 


59 


1 


,22 





.88 


0. 


5 





.8 


1 


.0 





.62 





.5 


1 


.6 





.6 





.9 


1 


.0 


1 


.27 


1 


.16 



124 NOTES ON IONIC MEDICATION 

lytic cell, but the ionic velocity is also important in calcu- 
lating the amount of an ion introduced into the body from 
without. If the two ions concerned have equal velocity, then 
the amount of each introduced at the two electrodes would 
be one-half of the figures calculated for the time, the current 
and the electro-chemical equivalent; but if the two ions con- 
cerned have different velocities, then the 'share of transport' 
of the ion with greater velocity will be greater than half, 
and that of the other ion will be less than half, in the ratio 
of difference of their velocities." 1 

Depth of Penetration of Ions.- — The introduction of ions into 
soft, good conducting tissues such as periodontal and gingival 
tissue is a much easier matter than through the skin a,nd in 
this respect ionic medication of oral tissues is much more 
effective than when the skin intervenes. To ascertain the 
depth of penetration of ions the author experimented on the 
gingival tissue of a dog. Incisions were made about the 
roots of several teeth to the depth of shallow pyorrhoea 
pockets, into which was introduced a metallic electrode 
wound with cotton-wool and saturated with 3 per cent, 
ferrous sulphate. A current of 5 ma. was passed in each 
pocket for three minutes, the operation performed in the 
same manner as for ionization in treatment of periodontal 
disease. Sections of the jaw were removed with tissues in 
situ, thoroughly washed, and placed in a 10 per cent, solu- 
tion of potassium ferricyanide; this colored the ferrous ions 
Prussian blue. It could then be seen that the ions had pene- 
trated the soft tissues in every direction, and also the alveolar 
bone to a depth of 15 mm. The ionized gum and periodontal 
tissue was cut in sections, and mounted for examination 

1 Jones, Lewis: Ionic Medication, p. 20. 



DEPTH OF PENETRATION OF IONS 



125 




Fig. 55. — Vertical section of ionized gum. E, oral epithelium; S, papilla 
of submucous tissue; C, connective tissue; P, periodontal membrane; B, 
alveolar bone. 




Fig. 56.— Vertical section of gum. E, oral epithelium; ,<S, submucous 
tissue; C, connective tissue; P, periodontal membrane. 



126 NOTES ON IONIC MEDICATION 

under the microscope. Sections were also prepared of similar 
tissue untreated. Fig. 55 shows photomicrograph of ionized 
tissue with a distinctly shaded appearance of the ions. 
Fig. 56 shows the contrast of untreated tissue. 

The depth of penetration of heavy metallic ions is enhanced 
in the case of periodontal tissue, when application is made 
beneath the epithelial surface of gum tissue, and for that 
reason it is more effective to place the electrode into the 
gingival trough, rather than ionize through the gum surface. 

Density. — The distribution of current on a charged con- 
ductor is on its surface; if the surface is spherical the distribu- 
tion is all over the surface evenly, but if it is pointed it is 
greatest at the point, so also if it is knife-edged, the edges 
display the greatest density, and the flat surfaces are less 
charged. These facts have an important bearing on the 
method of ionic medication of periodontal tissue, inasmuch 
as the small spear-shaped electrode which it is possible to 
introduce into so small an area intensifies the current and 
furnishes considerable penetration of ions with but a very 
small current strength in a very short time. Conduction is 
more perfect, and penetration quicker and deeper, than in 
many applications on other parts of the body, where the 
epidermis has to be penetrated and the electrode is of larger 
area, even though larger currents may here be employed. 

Therapeutic Effects. — The effects of different ions electro- 
lytically introduced into tissues have been observed and 
chronicled by many writers, principally from a clinical stand- 
point, but experimental evidence has also been recorded to 
show that certain ions possess marked antiseptic properties. 
Under the heading of antiseptic metallic ions, zinc, silver, 
copper and mercury have been specially mentioned for their 
antiseptic. .qualities, when introduced into tissues infected 



APPARATUS 127 

with microorganisms. These ions are also well tolerated by 
the tissues and promote healing. Although recently some 
doubt has been thrown on the sterilizing effect of these ions, 
the author is convinced that there is no real cause to doubt 
their antiseptic and healing effect on septic periodontal 
tissue. Ample clinical evidence of unmistakable nature dis- 
pels every shadow of doubt, and places these metallic ions 
among the most effective in sterilization of oral tissues, and 
promoting a metabolic change in tissues weakened by 
disease. 

Apparatus. — The source of current for ionic medication 
must be a continuous steady current, so controlled that only 
a fraction of a milliampere increase of current is permissible 
from the generator, when the resistance is released. A gal- 
vanic cell battery is a safe and convenient source of current 
which, if properly equipped with a reliable rheostat, answers 
the purpose admirably, but these batteries are often made 
for general medical purposes with current collectors, which 
increase and decrease the current abruptly. This kind is 
quite useless for the treatment of oral tissues. The battery 
should have a finely graded rheostat controlling the entire 
output of current and releasing it by a fraction of a milliam- 
pere at a time (Fig. 57) . A milliamperemeter is essential and 
one with a large dial reading -^ ma. to 5 ma. with a shunt 
in case larger reading is required, is the best. 

Dynamo Current. — Continuous current from the main is 
the most satisfactory source of supply; the principal require- 
ments in this case are a steady flow of current well controlled 
and so regulated and separated from the power-station dyna- 
mos that sudden rise or fall of current is impossible. The 
ionization apparatus of the Ritter Unit Equipment fulfils 
all the requirements for a safe and reliable outfit (Fig. 58). 



128 NOTES ON IONIC MEDICATION 

The principle here is to generate current by a small noiseless 
motor which is separately wound and worked by either alter- 
nating or continuous main current which it transforms into 
low voltage and sufficient amperage for ionization. 




Fig. 57. — Galvanic battery. 

One of the advantages of a motor transformer is the 
elimination of possibility of shock from short-circuiting with 
earth, which is a contingent to be guarded against with a 
main current switchboard. 



APPARATUS 



129 



A finely graded rheostat or current controller is the advan- 
tage of this particular outfit, the current can be so gradually 
increased that it is imperceptible until the limitation of the 
particular patient is reached. 



Q— — * 



;«/, 


J 


*y* 




I 











Fig. 58. — The Hitter unit equipment. A, pilot lamp; B. ionization gen- 
erator switch; C, ionization generator fuse; D, milliammeter ; E, ionization 
regulator button; F, ionization regulator dial; G, master switch; H, ioniza- 
tion terminal socket, patient circuit. 



A large-dialed milliamperemeter with a scale of T X F ma. 
registers the current strength in use. 

The Ritter Company also supply a portable Ionization 
Outfit (Fig. 59) which is practically the same as the Unit 
9 



130 



NOTES ON IONIC MEDICATION 



Equipment, suitable for those who do not require the larger 
outfit. This apparatus is admirably arranged for ionization 
work, possessing all the advantages of the transformer 
principle. 

Switchboard for continuous current from the main is another 
means of controlling current for ionization (Fig. 60) . In this 




Fig. 59 



case the chair should be insulated by a rubber mat under the 
base, metallic supports for cuspidor, water or gas pipes or any 
kind of metal in contact with the earth should be avoided, the 
saliva ejector must not be used. The current, after passing 
the rheostat on the switchboard, should be further controlled 
by a graphite rheostat (Fig. 61). This should be connected 
to the + terminal of the switchboard, and control the cur- 
rent passing to the patient, the indifferent electrode being 



APPARATUS 



131 



attached to the — terminal of the switchboard; the cur- 
rent is thus doubly controlled. This graphite rheostat has a. 
resistance of about 20,000 ohms, so that by releasing about 
20 volts pressure on the switchboard the current is completely 




Switchboard for ionic medication. 



resisted by the second rheostat, and by turning the glass dial 
it is released by a very gradual increase which is not per- 
ceived by the patient until sufficient current is obtained. 

Conducting cords should be of best quality, and secured 
firmly both to the generator and electrode handpiece. Loose 



132 



NOTES ON IONIC MEDICATION 



contacts cause rise and fall of current which is disagreeable 
to the patient. 

The poles should be tested after all connections are made 
by placing the two electrodes intended for use on a patient a 




Fig. 61. — Graphite dial rheostat. 



short distance apart in a glass of water to which has been 
added a few drops of phenolphthalein. On passing a few milli- 
amperes of current a purple coloring of the water will take 
place about the negative pole. When the correct poles are 
found (according to the + and — signs on the switchboard) 
the deflection of the milliamperemeter needle should be noted, 
if it deflects to the left of the dial, it must always deflect in 
that direction in future use to correctly correspond to the 



APPARATUS 



133 



marking of poles on the switchboard. A mark should be 
made on the wall plug and switchboard plug to ensure its 
being connected in correct polarity in future. 



Fig. 62. — The author's pyorrhoea electrodes. 

Electrodes for ionization of periodontal tissues should be 
of zinc, copper, or platinum, shaped to pass readily into 
gingival trough, interspaces or deep pockets (Fig. 62), and 
as large as possible compatible with the areas into which 
they must pass during treatment. Platinum can be used with 
any solution, but zinc and copper should only be used with 
solutions corresponding with those metals, like zinc chloride 
or copper sulphate. 




63. — The author's electrode handpiece. 



The electrodes should be interchangable so that they can 
be readily removed for sterilization, and attached firmly by 
a clutch at the end of an insulated handpiece. 

The indifferent electrode should be of metal (aluminum or 
nickel-plated brass) or carbon, and should be covered with 



134 



NOTES ON IONIC MEDICATION 



several layers of lint, forming a pad between it and the skin 
at the point of contact. The area should be large but the 




Fig. 64. — Hand electrode. 



site of contact does not materially matter. The hand 
electrode (Fig. 64) should be firmly held by the patient. 




Fig. 65. — -Wrist electrode. 



The wrist electrode (Fig. 65) should be tightly strapped into 
position, so also the chin electrode. 




Fig. 



-Carbon and water electrode. 



In case the metallic electrode causes blisters on the skin 
or is painful, a carbon and water electrode can be used 
with comfort, a little sodium chloride placed in the dish of 
tepid water and a rubber-covered conducting cord completes 
this form of contact. 



GENERAL CONSIDERATIONS 135 

General Considerations. — There are many minor points 
which arise during treatment of oral tissues, which tend to 
frustrate the use of electricity in these parts. These can 
always be overcome when full knowledge of the phenomena 
which govern these causes is possessed by the operator, who 
should be able to inspire the patient's confidence by his 
command of the work. Variations in resistance of the tissues 
at the site of contact; the difference in sensibility of root 
surfaces of different teeth and the presence of metallic fillings 
in sensitive cavities adjacent to parts being treated, are the 
most frequent causes of discomfort. These should be taken 
into consideration during the seance. If the tissues are thin 
and wasted or the gingival trough shallow, it is unnecessary 
to ionize it as long or with so great a current, as when they are 
thicker and deep pockets exist. So, too, if roots of teeth 
exhibit sensibility to current in these areas a small current 
will be sufficient where the greatest sensitiveness is present, as 
is often the case about the incisors. An excess of solution on the 
well covered electrode and keeping the electrode steady will 
permit of a greater current at those points, care being taken 
to reduce the current before moving on the metal point to 
an adjoining part. When metallic fillings are the cause of 
discomfort, the same precaution of steady contact will often 
overcome this difficulty, and care should here be taken not 
to abruptly move the electrode, suddenly breaking its con- 
tact with the filling, as this might stimulate the nerve fila- 
ments in connection with the nerves of the eye, and cause 
the impression of a flash of light, which is somewhat alarming 
to the patient. 

The current should be turned on gradually and the limita- 
tion of the patient's endurance tested up to the point, not 
only that it is being slightly felt, but in order that sufficient 



136 NOTES ON IONIC MEDICATION 

current is obtainable to secure proper penetration of ions, 
and also not to prolong the time. The endurance of slight 
discomfort should be requested during which it will often be 
found possible to raise the current strength considerably 
without increase of discomfort or pain. The best results are 
always obtained for patients with the least resistance to 
current, and those who are able to take 5 to 15 ma. with 
comfort. It should be the object of the operator to obtain 
at least 5 ma. in the molar regions and 3 ma. in the incisor 
regions. 

The application should be made directly into the gingival 
trough with an electrode capable of entering it, and the solu- 
tion conveyed on cotton-wool, which should be wound about 
the point of metal. No reliance can be placed on time-saving 
electrodes, such as can be found on the market, which are 
intended to ionize the entire gingival border at one time with 
the hope of penetrating the gum tissue and sterilizing the 
underlying gingival trough or pyorrhoea pockets. Such 
applications are not direct enough, and the penetration of 
ions is too superficial with the current strength which oral 
tissues will tolerate. 

For further information on electro-physics and electro- 
therapeutics applicable to dental use the reader is referred 
to larger medical and dental works on the subject. The 
author's work, Dental Electro-therapeutics, has been compiled 
with the object of collecting and condensing this information 
for dental use. 



INDEX. 



Abnormal spacing, 30, 86 
Acute septic infection of gums, 74 
Adenoids, 30 
Alimentary toxaemia, 46 
Alveolar bone, 41, 42, 43 
process, fragile, 43 

well-developed, 43 
Amoebae, 34 
Anions, 123 

Apparatus, electrical, 127 
Appendicitis, 47 

Arthritis, rheumatoid, 47, 50, 104 
Auto-intoxication, 45 



B 



Bacteria, 26, 31 

entry into tissues, 27 
varieties present, 33, 34 

Badcock, Mr., 97 

Barrett, M. J., 20, 34 

Battery, cell, 127 

Bennett, Norman, 18 

Benzoic acid wash, 74 

Black, G. V., 20 

Bone, rarefaction of, 20, 26, 34, 62, 
78, 103 

Bridge work, 30, 64, 96, 97, 98, 104 

Brown, Dr. C. P., 33 



Calculus, 25, 67, 75 
composition of, 25 
dissolved from roots, 29 
removal of, 70, 81, 83, 92, 108, 
110 



Calculus, salivary, 111 

subgingival, 25, 102, 110 
Chiavaro, A, 20, 34, 35 
Chronic periodontal disease, 77 

septic infection, 69 
Colyer, 20, 44, 100 
Congestion of gums, 74 
Constitutional disorders, 100, 107 
Crowns, 30, 58, 64, 75, 97, 99, 104 
Cure of pyorrhoea, 86, 104, 114, 115 



D 

Dead teeth, 64 
Degenerative changes, 34 
Dentures, ill-fitting, 30 
Diagnosis, early, 55 
of pyorrhoea, 76 
Diphtheroid bacillus, 34 
Drugs, 45 

"Dry pyorrhoea," 27, 69 
Dynamo current, 127 



Electrodes, hand, 133, 134 

platinum, 66, 70 

water, 134 

zinc, 68 
Electro-negative, 122, 123 
Electro-positive, 122, 123 
Electro-sterilization, 49, 50, 75 
Entamoeba buccalis, 34, 73 
Etiological factors, 23, 83, 87 
Etiology of periodontal disease, 23 
Extraction, 75, 78, 101, 104, 107, 

118 
Eye, diseases of, due to pyorrhoea, 
39, 47 



138 



INDEX 



Faulty articulation, 30, 58 
fillings, 60, 62, 97 

Flexner, 34 

Fcetid odor, 71, 109 

Food debris, 40, 51, 75 
soft, 30, 44 



Gastritis caused by periodontal 

disease, 47 
General considerations, electrical, 
135 
pyorrhoea, 108 
Gingival fold, 40 
infection, 48 

trough, 23, 26, 37, 44, 51, 65, 
67,83 
Gingivitis, 23, 45, 51, 76 
Goadby, 34, 47 
Goss, 34 

Gouty diathesis, 19, 22 
Grass, 34 
Grinding of teeth, 76, 80, 87, 88, 

92, 94 
Gums, 85, 92, 97, 104, 109 



II 



Hopewell-Smith, 19, 41 

Howe, 18, 39 

Hunter, 100 

Hygiene, oral, 64, 73, 85, 86, 104 

Hypersemia of periodontal tissue,40 



Immunity from bacteria, 32 
Inflammation of alveolar bone, 26 
of periodontal membrane, 26, 
37, 40 
Inorganic salts, 29 
Instrumentation, 70, 81, 83, 87, 92, 

108, 110 
Insufficient use of teeth, 30 
Interdental papilla, 31, 44 
Intractability of the disease, 45 
Iodin ions, 50, 66, 84, 95 



Ionic medication, 83, 120 
Ions, 120 

dissociation of, 121 

electro-positive and negative, 
123 

penetration of, 124 

therapeutic effects of, 126 
Ipecac, use of, 73 
Iridocyclitis, 47 
Irregularities of teeth, 30 
Irritant causes, 30 
Irritants in gingival trough, 32, 37 

local, 29, 37, 38 



K 



Rations, 123 



Lang, Wm., 47 
Lawford, J. B., 47 
Leukocytes, 26, 29, 37, 40 
Linea dura, 60, 62, 72, 78 
Local aspect of the disease, 23, 44, 
113 

inflammation, 24 

irritant causes, 29, 30, 42, 44 
Loosening of teeth, 42, 50 

M 

Malaise, 49 

Management of cases, 74, 85, 86, 

95, 103 
Metal poisoning, 45 
Micrococcus catarrhalis, 34 

pneumoniae, 34 
Microorganisms, 20, 31, 32 
Miller, 19, 31, 33 
Motor transformer, 128 
Mouth organisms, 34, 37 

protozoa, 34, 73 

wash, benzoic, 85 
Mucoperiodontal tissue, 43 
Mucus, removal of, 109 

N 

Necrosis, 108 
Neurasthenia from toxins, 47 



INDEX 



139 



Oral sepsis, 107 
Osteitis, rarefying, 28, 43, 44 
Osteoclasts, 28, 41 
Osteoporosis, 43, 62 



Pathogenic organisms, 28, 40, 71 
Pathological lesions, 44, 64 
Pathology of the disease, 37 
Pedley, Newland, 19 
Periodontal disease, etiology of, 23 
incipient stages, 23 
pathology of, 37 
prognosis of, 114 
treatment of, 65 
membrane, 38, 40 
Periodontoclasia, 72 
Pickerill, H. P., 19 
Plates, 96 

Platinum electrode, 66, 70 
Pocket, pyorrhoea, 40, 43, 64, 91, 

104, 107 
Polishing roots, 68, 81 
Prognosis of the disease, 1 14 
Protozoa, mouth, 34, 73 
Pus, 26, 28, 29, 34, 41, 46, 77, 106 
Pyorrhoea abscess, 105 

alveolaris, 23, 40, 45, 64, 65, 77 

R 

Radiography in diagnosis, 59, 77, 

101, 104 
Rarefying osteitis, 26, 43, 44, 62, 

78, 103 
Recurrence of the disease, 103 
Regeneration of bone, 81, 117 
Rheostat, 132 
Rheumatic symptoms caused bv, 

47, 49, 104 
Rheumatoid arthritis caused by, 

47, 50, 51, 104 
Root surgery, 81, 83 



Saliva, control in ionization, 69 
Salivary calculus, 75, 80, 95 
Scalers, 56, 60, 70 
Scaling, 70, 81, 83, 87, 92, 108 
Septic infection of a;ingival trough, 
67 



Silk, cleaning with, 73 
Silver nitrate, 75, 109 
Smith, Dr. T. Sydney, 82 
Spirochetes in mouth, 34, 53, 54 
Splints and ligatures, 81, 89, 90, 91 
Stagnation area, 24, 37, 45 
Staphylococcus, 34 
Streptococcus, 34, 46, 51 
Subgingival calculus, 25, 27, 38, 49, 

51, 91, 94 
Switchboard for ionization, 129 
Syphilis, influence of, in periodontal 

disease, 21, 45, 116 



Talbott, 19, 44 

Teeth, extraction of, 78, 101, 104, 

107 
Temperature in periodontal disease, 

49 
Thomson, J. G. and D., 53 
Tonsillitis caused by oral sepsis, 47 
Toxemia, 28, 46, 48, 53 
Toxins in periodontal disease, 34, 

47, 48, 119 
Traumatic occlusion, 92, 93 
Treatment of periodontal disease, 

65 
Trench mouth, 54 

U 

Undue stress in dentin, 29, 30, 58, 
63, 76, 96 

V 

Vaccine therapy, 51, 102, 112 

W 

Wallace, Dr. Sim, 66 

X 

X-ray, examination by, 59, 77, 101, 
104 

Z 

Zinc chloride, 68, 69, 70 

ionization, 49, 50, 52, 117 
Znamensky, 21, 38, 39, 40 



